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Idea's  Scries  of  PocI(et  Tcxt=5ool<s. 

NERVOUS  AND  MENTAL  DISEASES. 


A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS. 


CHARLES  S.  POTTS,  M.D., 

Instructor  in  Nervous  Diseases,  University  of  Pennsylvania;  Assistant 
Neurologist  to  the  University  Hospital,  Philadelphia;  Con- 
sulting Physician  to  the  Hospital  for  Insane, 
of  Atlantic  Co.,  N.  J. 


SERIES   EDITED  BY 

BEEN    B.   GALLAUDET,   M.D., 

Demonstrator  of  Anatomy  and  Instructor  in  Surgery,  College  of  Physicians  and  Surgeons, 
Columbia  University,  New  York ;  Visiting  Surgeon,  Bellevue  Hospital,  New  York. 

ILLUSTRATED  WITH  EIGJHTY-EIGHT  ENGRAVINGS. 


LEA   BROTHERS   &   CO., 
PHILADELPHIA    AND    NEW    YORK. 


39-/ 


Entered  according  to  Act  of  Congress,  in  the  year  1900,  by 

LEA  BROTHERS  &  CO., 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington.    All  rights  reserved. 


WESTCOTT    a   THOMSON, 
ELEOTROTYPERS,    PHILADA. 


PREFACE 


A  KNOWLEDGE  of  SO  many  branches  of  medicine  is  re- 
quired of  the  medical  student  of  to-day,  and  the  time  at  his 
disposal  is  so  comparatively  limited,  that  a  manual  embody- 
ing only  the  essentials  of  the  subject,  such  as  this  aims  to  do, 
can  at  least  prove  useful.  At  the  same  time,  while  believed 
to  contain  all  that  is  necessary  for  a  working  knowledge  of 
nervous  and  mental  diseases,  the  book  is  not  intended  to  take 
the  place  of  any  of  the  many  excellent  and  more  complete 
text-books  that  now  exist,  but  to  serve  as  an  introduction  to 
their  study,  if  further  knowledge  is  desired.  While  written 
primarily  for  students,  it  is  hoped  that  it  may  also  prove  of 
use  to  the  general  practitioner. 

It  is  obvious  that  the  anatomy  of  the  nervous  system  could 
not  be  adequately  treated  in  a  work  of  this  size ;  but  enough 
of  its  histology  and  physiology  has  been  discussed  to  refresh 
the  memory  of  the  student  upon  points  that  are  essential  to 
the  proper  understanding  of  many  of  the  pathological  condi- 
tions and  the  symptoms  arising  therefrom. 

Since  a  mere  statement  that  certain  symptoms  exist  is  of 
little  value  to  the  student  unless  it  is  followed  by  instructions 
as  to  their  recognition  and  interpretation,  general  symptoma- 
tology and  methods  of  examination  have  been  fully  treated. 
Considerable  space  has  also  been  devoted  to  therapeutic 
measures,  including  not  only  medication,  but  also  the  non- 
medicinal  remedial  agencies,  such  as  electricity,  massage, 
hydrotherapeutics,  rest-cure,  etc. 

3 


4  PREFACE. 

The  System  Diseases  have  been  classified  according  to  the 
neuron  or  neurons  affected.  In  the  author's  opinion  this  is 
the  correct  method.  Although  it  may  not  be  strictly  accurate, 
owing  to  the  complicated  nature  of  the  subject,  it  is  believed 
to  be  as  nearly  so  as  the  present  state  of  knowledge  permits. 

Brief  descriptions  of  tetanus  and  hydrophobia  have  been 
given.  These  are  omitted  in  many  of  the  text-books  ;  but 
as  the  nervous  system  is  the  seat  of  the  lesions,  it  seems 
proper  to  incorporate  them. 

The  section  on  Mental  Diseases,  while  necessarily  brief,  may, 
owing  to  its  very  brevity,  be  read  when  a  more  pretentious 
treatise  would  be  avoided.  It  is  hoped,  therefore,  that  the 
student  may  obtain  an  intelligent  idea  of  these  disorders,  so 
much  neglected  by  the  average  practitioner.  The  author 
knows  of  nothing  in  medicine  concerning  which  there  is  so 
much  ignorance. 

The  various  text-books,  notably  those  of  Gowers,  Dana, 
Gray,  Mills,  Church  and  Peterson,  Clouston,  Regis,  Spitzka, 
and  the  Text-Booh  of  Nervous  Diseases  by  American  Authors, 
edited  by  Dercum,  have  been  referred  to.  The  author  would 
also  acknowledge  his  obligations  to  various  papers  and  mono- 
graphs by  B.  Sachs,  Osier,  H.  C.  Wood,  Bastian,  Collins, 
Patrick,  Herter,  Sailer,  and  many  others,  and  to  A  Text-Book 
of  Pathology  by  Stengel. 

CHARLES  S.  POTTS. 

1629  Locust  St.,  Philadelphia. 


CONTENTS. 

NERVOUS   DISEASES 


CHAPTER    I. 

PAGE 

Introductory  or  Histology 19 

CHAPTER    II. 
General  Pathology 31 

CHAPTER  III. 

General  Symptomatology  and  Methods  of  Examination  .   .      83 

CHAPTER  IV. 
General  Therapeutic  Measures 56 

CHAPTER  V. 
Symptomatic  Disorders 78 

CHAPTER  VI. 
Diseases  of  the  Peripheral  Nerves 93 

CHAPTER  VII. 
Diseases  of  the  Cranial  Nerves .    106 

CHAPTER  VIII. 
Diseases  of  the  Spinal  Nerves 149 

CHAPTER  IX. 

Inflammation  of  the  Meninges 173 

5 


6  CONTENTS. 

CHAPTER  X.  PAGE 

System  Diseases 190 

CHAPTER  XI. 

Diffuse  and  Local,  Diseases  of  the  Brain 232 

CHAPTER  XII. 

Focal  and  Diffuse  Diseases  of  the  Spinal  Cord 283 

CHAPTER  XIII. 
Diffuse  Diseases  Affecting  the  Brain  and  Cord 313 

CHAPTER  XIV. 
General  and  Functional  Diseases 323 

CHAPTER   XV. 

Vasomotor  and  Trophic  Diseases 376 


MENTAL    DISEASES. 

General  Considerations 395 

Insanity 397 

Idiocy 434 


NERVOUS  AND  MENTAL  DISEASES. 


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NERVOUS  DISEASES. 


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CHAPTER  I. 

INTRODUCTORY  OR  HISTOLOGY. 

The  Neuron. 

The  neuron — constituents  of:  The  nervous  system  is  made 
up  of  a  vast  number  of  units,  termed  neurons.  Each  neuron 
is  essentially  of  the  same  structure,  and  consists  of  a  ceU-hody, 
containing  a  nucleus,  which  in  turn  contains  a  nucleolus ; 
from  this  cell-body  arise  one  or  more  processes,  usually  the 
latter,  termed  dendrites  ;  and  a  process  which  differs  in  struct- 
ure and  function  from  these,  called  the  axis-cylinder  process, 
or  axon  (Fig.  1). 

It  is  important  to  remember  that  each  neuron  is  anatomi- 
cally and  physiologically  independent,  and  that  it  is  not  con- 
nected by  continuity,  but  by  contiguity,  with  any  other  neuron. 

The  cell-body  is  composed  of  protoplasm  imbedded  in  a 
network  of  fibres.  In  most  cells  are  found  in  this  network 
granular  masses  which  stain  deeply,  known  as  the  ehromo- 
philic  granules. 

The  dendrites  are  composed  of  protoplasm  similar  to  that 
of  the  cell-body,  and  really  part  of  it.     They  are  broad  and  ■ 
thick  at  their  origin,  and  become  narrower  as  they  divide 
and  subdivide.     Upon  them  are  a  number  of  small  lateral 
projections,  termed  gemmules. 

The  axon  arises  either  from  the  cell-body  or  a  dendrite, 
usually  the  former.  It  differs  structurally  from  the  cell-body 
and  dendrite,  being  composed  of  Jirie  threads  imbedded  in  a 
clear  substance  which  is  probably  protoplasm.  Its  surface  is 
smooth,  and  the  calibre  is  maintained  without  apparent  dim- 

19 


20 


INTRODUCTORY  OR  HISTOLOGY. 


Fig.  1. 


/m\ 


Neuron  with  long  axon  proceeding  as  an 
axis-cylinder  of  a  nerve-fibre,  n,  nerve- 
cell  proper;  d,  dendrites;  x,  axon;  dg, 
dendrite  showing  gemraulse  ;  a  d  g,  apical 
dendrite  with  gemmulfe;  c,  collaterals; 
e,  end-tufts.  Pyramidal  cell  t>l'  the  cere- 
bral cortex  (S.  Kam6n  y  Cajal). 


iniition  for  some  distance 
from  the  cell-body.  The 
length  of  an  axon  varies 
from  a  fraction  of  a  millime- 
tre to  nearly  a  hundred  cen- 
timetres (some  fibres  of  the 
pyramidal  tract).  The  short 
axons  divide  into  a  great 
number  of  branches ;  such 
cells  have  been  termed  den- 
dr axons,  or  Golgi  cells  of 
the  second  type  (Fig.  2). 
The  long  axons  at  intervals 
give  oif  branches  at  right 
angles  to  their  course, 
termed  collaterals.  This 
type  of  cell  is  called  an  in- 
axon,  or  Golgi  cell  of  the 
first  type.  The  axons  and 
collaterals  end  by  splitting 
into  a  brush-like  arrange- 
ment, termed  the  end-brush, 
or  end-tufts  (Fig.  1).  Ax- 
ons and  their  collaterals, 
excepting  for  a  short  dis- 
tance from  their  ending,  are 
enveloped  in  a  medullary 
sheath. 

Functions :  The  cell-body 
may  either  originate  efferent 
nerve-impulses  of  various 
sorts  (cortical  cells) ;  modi- 
fying impulses  received 
from  another  neuron  (gan- 
glion-cells of  cord) ;  or  re- 
ceive and  recognize  afferent 
or  sensory  impressions. 

Efferent  impulses  are  car- 
ried away  from  the  cell-body 
by    the    axon,    which    may 


THE  NEURON.  21 

therefore  end  either  by  .surrounding  with  its  end-brushes  the 
dendrites  of  another  cell,  or  in  the  "  terminals  "  of  the  muscles 
(Fig.  3). 

Sensory  impressions  are  collected  either  by  an  axon  from 
the  periphery  (sensory  end-organs)  or  from  the  axon  of  an- 
other neuron  by  the  dendrites.  These  latter  probably  also 
collect  nutrient  materials  from  the  blood  for  the  cell-body. 
In  addition  to  the  neuron  contiguous  to  the  axon,  each  neuron 
is  brought  into  relation  with  a  number  of  other  neurons  by 
means  of  the  collaterals. 


Neuron  with  short  axon  immediately  breaking  up  into  numerous  fine  filaments,  n  c, 
nerve-cell  proper;  x,  axon  ;  d,  dendrites.    From  the  cerebellum  (Andriezen). 

The  life  of  the  processes  is  dependent  upon  the  cell-body  ; 
if  this  is  destroyed, -they  degenerate  and  die  ;  or  if  part  of  a 
process  is  cut  off  from  the  cell-body  by  any  reason,  it  dies.^ 

Neurons — their  relations  to  each  other  :  The  cells  are  found 
in  the  gray  matter  of  the  brain,  cord,  and  ganglia  of  the 
peripheral  nerves.  A  group  of  them  which  together  control 
some  particular  function  of  the  body  is  known  as  a  centre ; 

'  In  such  an  event  the  entire  neuron  suffers,  but  not  so  rapidly  nor  to 
such  an  extent  as  the  separated  part. 


22 


INTRODUCTORY  OR  HISTOLOGY. 


for  instance,  that  collection  of  cells  situated  in  the  lower  part 
of  the  central  convolutions  which  controls  the  movements  of 
the  tongue  is  the  tongue-centre. 


Tracts. 

Projection-fibres :  The  axons  form   the  various  tracts,  and 
are  found  principally  in   the   peripheral  nerves  and  white 

Fig.  3. 


Illustrating  the  varying  relations  of  neurons  to  each  other.  NC,  nerve-cell ;  B, 
dendrites ;  x,  axon ;  C,  collaterals  ;  E,  end-brush ;  31,  muscle-fibre  (after  Ober- 
Bteiner). 

matter  of  the  brain  and  cord.  Those  fibres  which  connect 
cortical  centres  directly  with  cells  in  the  basal  ganglia,  the 
nuclei  in  the  pons  and  medulla  and  in  the  gray  matter  of  the 
cord,  are  termed  jprojection-jibi'es  (Fig.  4).    These  fibres  form 


TRACTS. 


23 


the  pathways  by  which  motor  impulses  are  carritid  from  the 
cortex  to  the  spinal  centres  ;  and  by  which  sensory  impressions 
are  brought  from  certain  ganglionic  masses  in  the  medulla 


Fig.  4. 


The  projection-tracts  joining  the  cortex  with  lower  nerve-centres.  Sagittal  section, 
showing  the  arrangements  of  tracts  in  tlie  internal  capsule,  a,  tract  from  the 
frontal  lobe  to  the  pons,  thence  to  the  cerebellar  hemisphere  of  the  opposite 
side  ;  b,  motor  tracts  from  the  central  convolutions  to  the  facial  nucleus  in  the 
pons  and  to  the  spinal  cord  ;  its  decussation  is  indicated  at  K ;  c,  sensory  tract 
from  posterior  columns  of  the  cord,  through  the  posterior  part  of  the  medulla, 
pons,  crus,  and  capsule  to  the  parietal  lobe ;  d,  visual  tract  from  the  optic  thala- 
mus (ot)  to  the  occipital  lobe  ;  e,  auditory  tract  from  the  int.  geniculate  bodf 
(to  which  a  tract  passes,  from  the  viii  N  nucleus,  J)  to  the  temporal  lobe ;  F, 
superior  cerebellar  peduncle  ;  g,  middle  cerebellar  peduncle  ;  h,  inferior  cere- 
bellar peduncle ;  cn,  caudate  nucleus  ;  cq,  corpora  quadrigemina ;  vt,  fourth 
ventricle.    The  numerals  refer  to  the  cranial  nerves. 


and  base  of  the  brain  to  the  cerebral  cortex  (see  Motor  and 
Sensory  Tracts).  These  pathways,  together  with  certain  col- 
umns in  the  spinal  cord  and  the  peripheral  nerves,  form  the 
motor  and  sensory  tracts,  which  are  therefore  composed  of  two 
or  more  kinds  of  neurons. 

Association- tracts  and  -centers :  All  that  part  of  the  cortex 
(comprising  about  two-thirds)  not  connected  with  projection- 
fibres — i.  e.,  that  part  in  which  are  not  included  the  sensory 
and  motor  regions  and  special  sense-centres — contains,  ac- 
cording to  Flechsig,    centres  in  which  the  various  sensory 


24 


INTRODUCTORY  OR  HISTOLOGY. 


impressions  are  collected,  arranged,  and  coordinated.  These 
centres  are  termed  by  him  association-centres,  and  are  con- 
nected with  the  sensory  and  motor  regions  and  special  sense- 
centres  by  collections  of  fibres,  termed  association-tracts 
(Fig.  5). 

Fig.  5. 


The  association-fibres,  a,  between  adjacent  convolutions  ;  B,  between  frontal  and 
occipital  areas;  c,  between  frontal  and  temporal  areas,  cingulum;  d,  between 
frontal  and  temporal  areas,  fasciculus  uncinatus ;  e,  between  occipital  and  tem- 
poral areas,  fasciculus  longitudinalis  inferior;  cn,  caudate  nucleus;  ot,  optic 
thalamus. 

Fibres  also  connect  the  centres  of  one  side  with  the  corre- 
sponding ones  in  the  other.  These  are  termed  commissural 
fibres. 

The  location  of  the  cerebral  centres  will  be  given  under 
Cerebral  Localization. 


The  Motor  Tract. 

The  motor  tract  has  its  origin  in  the  motor  centres  situ- 
ated about  the  fissure  of  Rolando.  The  axons  of  these 
cells  (Fig.  6)  converge  as  they  pass  down  through  the 
brain  until  they  reacli  the  internal  capsule,  where  they 
form  a  compact  bundle  occupying  most  of  the  posterior  limb. 
They  pass  hence  through  the  crus,  pons,  and  medulla,  and  in 
the  lower  part  of  the  latter  most  of  them  cross  to  the  oppo- 
site side.     Previous  to  this,  however,  in  the  lower  part  of 


THE  MOTOR   TRACT. 


25 


the  pons  and  the  upper  part  of  the  medulla,  fibres  liave  heen 
given  off,  which  decussate  and  pass  to  the  nuclei  of  the  inot 
cranial  nerves  (Fig.  6).      Those  fibres  which  cross    iu    * 


or 
the 


Fig.  6. 


Diagram  of  the  direct  or  voluntary  motor  tract,  showing  the  centre  of  the  motor 
impulses  from  the  cerebral  cortex  to  the  voluntary  muscles,  m,  muscles ;  n, 
cells  of  nuclei  of  motor  cranial  nerves  in  pons  and  medulla;  a,  motor  cells  in 
anterior  horns  of  spinal  cord  ;  dpi,  direct  pyramidal  tract  \  cpf,  crossed  pyram- 
idal tract:  pc,  peripheral  cranial  nerve;  ps,  peripheral  spinal  nerve  (Van 
Gehuchtcn). 

lower  part  of  the  mednlla  ])ass  down  in  the  posterior  part  of 
the  lateral  columns  of  the  cord,  as  the  crossed  pyramidal 
tract^  and  the  "  terminals"  of  these  fibres  surround  the  cells 
in  the  anterior  horns.     The  axons  from  these  cells  and  from 


26 


INTRODUCTORY  OR  HISTOLOGY. 


the  cells  of  the  motor  cranial  nerve-nuclei,  mentioned  above, 
form  the  motor  divison  of  the  peripheral  nerves. 

The  comparatively  few  fibres  which  have  not  crossed  pass 
down  in  the  middle  portion  of  the  anterior  columns,  forming 
the  dh-eot  pi-yamidal  tract,  or  column  of  Tiirck,  the  fibres  of 
which  cross  in  the  anterior  commissure  at  diiferent  levels 
and  also  connect  with  the  motor  cells  in  the  anterior  horns 
(Fig.  6). 

Function :  This  motor  tract  is  concerned  in  all  voluntary 
muscular  movements.     The  cortical  cells  originate  the  im- 


FiG.  7. 


CereUellum 


Diagram  of  the  indirect  or  involuntary  motor  tract. 

pulses  and  control  or  inhibit  the  functions  of  the  spinal  cells. 
The  cord-cells  receive  and  distribute  the  motor  impulses  to 


THE  SENSORY  TRACTS.  27 

the  muscles,  maintain  their  nutrition,  and  with  the  sensory 
cells  form  reflex  centres. 

There  is  another  tract,  known  as  the  indirect  motor  tract, 
which,  arising  in  the  central  convolutions,  forms  connections 
with  the  optic  thalamus  and  the  pons  nuclei,  and  passes 
hence  to  the  cerebellum,  from  which  another  series  of  fibres 
goes  to  the  motor  tract  in  the  cord  (Fig.  7). 

This  tract  plays  a  part  in  coordinating  muscular  move- 
ments and  automatic  acts,  and  possibly  in  maintaining  muscle- 
tone. 

The  Sensory  Tracts. 

The  sensory  tracts  are  much  more  complicated  and  their 
course  not  so  well-known  as  the  motor.  There  are  probably 
different  pathways  for  the  various  forms  of  sensation — viz., 
tactile,  pain,  temperature,  and  muscle.  The  cells  of  the 
first  neuron  are  situated  in  ganglia  upon  the  posterior  nerve- 
roots  or  sensory  cranial  nerves,  as  the  case  may  be.  Each 
of  these  cells  gives  off  a  long  process,  possibly  a  dendrite, 
which  runs  to  the  periphery  as  part  of  a  peripheral  nerve, 
and  ends,  according  to  the  peculiar  form  of  "  sensation  "  that 
it  conducts,  in  one  of  the  various  specialized  end-organs  in 
either  the  skin,  muscles,  or  organs  of  special  sense.  From 
the  cell  the  axon  also  arises,  enters  the  spinal  cord  as  part 
of  a  posterior  root,  and  divides  into  a  long  ascending  and 
a  short  descending  branch.  Some  of  the  former  pass  up  the 
cord  in  the  posterior  columns,  in  the  nuclei  of  which  they  end. 
The  cells  of  these  nuclei  are  the  beginning  of  another  neuron, 
the  axons  of  which  forip  the  lemniscus  or  fillet,  which 
also  receives  fibres  from  the  sensory  cranial  nerve-nuclei 
(Fig.  8).  Here  they  decussate  and  the  fibres  run  to  cells  in 
the  optic  thalamus,  axons  from  the  cells  of  which,  after  pass- 
ing through  the  posterior  part  of  the  internal  capsule,  reach 
the  cortex,  where  they  are  brought  into  relation  with  the 
motor  neurons.  Sensations  of  touch  are  probably  conducted 
by  this  path. 

Other  fibres  leave  the  nuclei  of  the  posterior  columns,  and 
by  means  of  the  inferior  cerebellar  peduncles  of  the  same 
side  reach  the  cerebellum.  Hence,  another  series  of  fibres, 
by  way  of  the  superior  peduncles,  passes  to  the  optic  thalamus 


28 


INTRODUCTORY   OR  HISTOLOGY. 


and  red  nucleus,  and  hence  by  other  neurons  tlie  tract 
reaches  the  cortex.  Sensations  from  the  muscles  and  joints 
probably  travel  by  this  route  (Fig.  9). 

Fig.  8. 


The  direct  sensory  tract,  p  s,  peripheral  spinal  nerves ;  pg,  ganglion  on  posterior 
roots  of  spinal  nerves  ;  g  t,  Gower's  tract ;  cgt,  columns  of  GoU  and  Burdach ; 
en,  nucleus  cuneatus  ;  g n,  nucleus  gracilis;  a,  cells  in  posterior  horn;  pc, 
peripheral  cranial  nerve ;  g,  ganglion  on  cranial  sensory  nerve  ;  n,  cells  of 
cranial  sensory  nerves  in  medulla;  /,  fillet;  o/,  optic  thalamus. 

Another  series  of  fibres,  after  entering  the  cord,  surrounds, 
with  its  terminals,  cells  in  the  posterior  horns  of  the  gray 
matter.     From    these   cells  axons  arise  which    pass   to  the 


THE  SENSORY  TRACTS. 


29 


opposite  side,  where  they  form  the  antero-lateral,  or  Gower's, 
tract  (Fig.  8).  Part  of  the  fibres  of  this  column,  probably 
by  way  of  the  fillet,  reach  the  optic  thalamus  and  corpora 
quadrigemina,   from   which  points  their  course  is  doubtful ; 


Fig.  9. 


ellum 


Indirect  sensory  tracts.    dc<,  direct  cerebellar  tract.    The  numbers  represent  the 
different  series  of  neurons. 


while  others  by  way  of  the  superior  peduncles  go  to  the 
cerebellum.  Sensations  of  pain  and  temperature  are  probably 
conducted  by  this  tract. 

Still   other  fibres  join   the   cells  of  Clarke's   column,  the 


30  INTRODUCTORY  OR  HISTOLOGY. 

axons  of  which  form  the  direct  cerebellar  tract,  which, 
without  decussation,  ends  in  the  cerebellum  through  the  in- 
ferior peduncle  (Fig,  9).  This  tract  also  conducts  sensations 
from  the  muscles,  and  probably  also  has  some  connection  with 
the  sympathetic  system. 

Collaterals  from  the  sensory  fibres  pass  into  the  gray  mat- 
ter, where  they  join  the  motor  and  sensory  cells.  By  means 
of  these  and  the  short  descending  branches  the  different 
levels  and  various  sensory  tracts  are  brought  into  relation. 

The  special  sense-tracts  will  be  described  in  connection  with 
the  diseases  of  their  peripheral  nerves. 

In  addition  to  the  cells  and  their  processes  just  described, 
the  nervous  system  is  composed  of  connective  tissue,  neurog- 
lia, bloodvessels,  and  lymphatics,  the  whole  being  enveloped 
in  the  membranes  which  constitute  the  meninges. 


CHAPTER   II. 

GENERAL  PATHOLOGY. 

The  functions  of  the  nervous  elements  may  be  impaired 
by  disease  or  abnormality  of  any  of  their  structures. 

INFLAMMATION. 

In  the  nervous  system,  as  elsewhere,  inflammation  is  the 
reaction  of  the  organism  to  an  irritant.  This  irritant  may  be 
the  product  of  microbic  action  or  tissue-change,  or  of  some 
chemical  substance,  as  lead,  alcohol,  arsenic,  etc.  This  in- 
flammation may  be  simple,  without  exudation  or  destruction 
of  tissue ;  or  there  may  be  exudation,  and  destruction  of 
nerve-tissue,  with  the  formation  of  connective  tissue  or  pus ; 
furthermore  the  process  may  be  chronic  or  acute. 

The  following  table  (from  Dana)  shows  the  various  forms 
and  their  causation : 

Classification  of  Inflammations. 


FOKM. 

Cause. 

Example. 

Simple  exudative,  with  or 

Microbic  or  toxic. 

Meningitis ; 

without  necrosis. 

Poliomyelitis. 

Purulent,  with  or  without 

Microbic  or  necrobic. 

Meningitis  and  encepha- 

necrosis. 

litis  ; 
Acute  purulent  myelitis. 

Productive    or    prolifera- 

Microbic or  toxic. 

Chronic  meningitis ; 

tive. 

Leprous  neuritis. 

DEGENERATIONS  AND  SCLEROSES. 

By  degeneration  we  mean  a  gradual  death  of  the  nerve-cells 
and  their  processes.  This  may  be  acute,  chronic,  primary, 
or  secondary. 

Acute  degeneration  is  due  to  the  cutting  otf  of  the  blood- 

31 


32  GENERAL  PATHOLOGY. 

supply,  to  traumatism,  and  the  effects  of  inflammation.  It 
produces  the  condition  known  as  ueGrosis  or  softening. 

Chronic  degeneration  is  caused  by  the  continued  action  of 
various  poisons,  especially  metallic  and  those  of  infectious 
diseases,  and  is  accompanied  by  the  formation  of  connective 
tissue  and  consequent  sclerosis.' 

A  primary  degeneration  is  one  due  either  to  some  inherent 
defect,  as  in  the  muscular  dystrophies ;  or  to  the  direct  action 
of  some  poison,  as  in  locomotor  ataxia. 

A  secondary  degeneration  is  due  either  to  the  cutting  off  of 
a  nerve-fibre  from  its  tropliic  centre — i.  e.,  the  cell-body — as 
the  degeneration  of  the  pyramidal  tract  following  a  hemor- 
rhage into  the  internal  capsule ;  or  to  a  deficiency  in  the 
blood-supply,  as  in  old  age  due  to  obliterating  arteritis. 

Grliosis.  When  we  have  an  extensive  proliferation  of  neu- 
roglia the  process  is  termed  gliosis,  or  gliomatosis.  This  proc- 
ess is  found  in  syringomyelia. 

General  considerations  :  It  must  be  remembered  that  nerve- 
cells  destroyed  do  not  develop  again.  The  nerve-fibres  in  the 
brain  and  cord,  if  destroyed,  are  not  regenerated,  but  a  periph- 
eral nerve-fibre  may  be  destroyed,  and  if  its  trophic  centre 
is  intact  it  will  grow  again. 

Other  forms  of  disease  which  may  affect  the  nervous  ele- 
ments are  :  malformations,  incomplete  or  defective  develop- 
ment ;  hypersemia ;  anaemia ;  oedema  ;  diseases  of  the  blood- 
vessels ;  hemorrhage ;  thrombosis  or  embolism  ;  atrophy  ; 
softening  ;  syphilis  and  tuberculosis  ;  tumors  ;  parasites  ; 
functional  disorders ;  disorders  associated  with  glandular 
defects ;  and  disorders  of  nutrition,  as  myxoedema  and  acro- 
megaly. 

^  In  this  process  it  is  probable  that  there  is  also  some  increase  of  the 
neuroglia. 


CHAPTEE    III. 

GENEKAL  SYMPTOMATOLOGY  AND  METHODS  OF 
EXAMINATION. 

The  symptoms  cuusecl  when  a  nerve  centre  or  tract  is  af- 
fected by  any  of  the  lesions  mentioned  in  the  preceding 
chapter  depend  upon  whether  the  lesion  is  destructive  or  irri- 
tative. If  destructive,  the  function  of  the  involved  part  is 
diminished  or  destroyed  ;  if  irritative,  its  function  is  increased. 
Symptoms  produced  by  a  combination  of  these  two  kinds 
of  lesions  may  be  present ;  for  instance,  a  cerebral  tumor, 
while  it  causes  destruction  of  the  nerve-elements  directly  af- 
fected, will  cause  irritation  of  the  neighboring  jjarts.  A  lesion 
which  may  at  first  be  irritative  may  finally  be  destructive. 
For  instance,  a  meningitis  may  at  first  cause  increased  cere- 
bral action  with  convulsions,  etc.  ;  but  finally,  as  the  disease 
progresses,  these  parts  are  destroyed  and  coma  and  paralysis 
result. 

Symptoms  resembling  those  produced  by  an  irritative  lesion 
may  also  be  produced  if  the  higher  or  inhibitory  centres  in 
the  brain  are  destroyed,  thus  allowing  over-action  of  the  lower 
or  spinal  centres  to  occur  (see  Contracture). 

Neurosis  and  psychosis  :  The  general  term  for  any  derange- 
ment of  the  nervous  system,  exclusive  of  those  of  the  higher 
or  mental  functions,  is  neuroms.  This  term  is  more  commonly 
applied,  however,  to  disorders  of  di  functional  nature,  or  those 
in  which  we  can  find  no  apparent  organic  cause. 

A  disordered  mental  state  is  known  as  a  2}sychosis. 

The  following  prefixes  are  used  to  indicate  derangements 
of  function  of  the  nervous  system  :  viz.,  "  hyper,"  meaning 
excess;  "hypo,"  which  means  diminution;  "a"  or  "an," 
which  indicates  entire  loss;  and  "para"  meaning  perversion. 
For  example,  we  speak  of  hypercesthesia,  meaning  increased 

3— N.  D.  33 


34  GENERAL  SYMPTOMATOLOGY. 

sensibility ;  ancesthesla,  or  loss  of  sensibility  ;  and  parcesthesia, 
for  perverted  sensibility. 

Symptoms  caused  by  disorders  of  the  higher  or  psychical 
centres :  These  are  mostly  found  in  mental  diseases,  as  in- 
sanity, idiocy,  and  imbecility  and  will  be  discussed  under  that 
head.  We  may,  however,  find  loss  of  will ;  failure  of  mem- 
ory ;  lack  of  control ;  inability  to  concentrate  the  attention ; 
mental  excitement ;  or  depression,  in  patients  who  are  not 
insane  (see  Neurasthenia  and  Hysteria). 

Consciousness  may  be  considered  one  of  the  higher  func- 
tions of  the  brain.  Impairment  or  loss  of  it  is  an  important 
symptom  of  many  nervous  diseases  both  organic  and  func- 
tional. This  loss  may  be  due  to  disease  of  the  brain-cortex 
or  to  the  inhibitory  action  of  lesions  elsewhere  in  the  brain. 
For  instance,  the  loss  of  consciousness  in  cerebral  hemorrhage 
is  due  probably  to  an  irritative  inhibitory  action  on  the  cortex. 

Stupor  and  coma  :  If  the  patient  can  be  partially  aroused 
by  ordinary  stimuli,  we  call  the  condition  stupor.  If  he  can- 
not be  aroused,  we  term  it  coma. 

In  stupor  the  reflexes  are  active ;  in  coma  they  are  not,  and 
the  pupils  are  either  contracted  or  dilated  and  immobile ;  the 
pulse  slow,  sometimes  irregular  or  frequent ;  and  the  respira- 
tion slow  and  weaker  than  normal.  The  relaxation  of  the 
palate  allows  it  to  vibrate  with  the  passing  current  of  air, 
causing  the  so-called  stertorous  breathing.  Frequently  the 
respiration  is  of  the  Cheyne-Stokes  type. 

In  examining  a  case  of  stupor  or  coma  the  head  should  be 
carefully  looked  over  for  possible  injury ;  the  existence  of 
paralysis  or  spasm  detected ;  the  presence  or  absence  of  re- 
flexes, superficial  and  deep,  noted ;  the  breath  examined  for 
the  odor  of  alcohol  or  opium ;  and  the  urine,  for  evidences 
of  nephritis  or  diabetes.  Furthermore,  it  must  be  ascertained 
whether  the  patient  is  an  epileptic  who  has  just  had  a  convul- 
sion ;  or  is  a  syphilitic  or  hysteric.  The  differential  diagnosis 
of  coma  will  be  discussed  under  the  head  of  Apoplexy. 

Symptoms  Caused  by  Overaction  of  the  Motor  Tract. 

Convulsions  :  A  convulsion,  as  defined  by  Herter,  consists  of 
"  involuntary,  paroxysmal,  purposeless  muscular  contractions 


OVERACTION  OF  THE  MOTOR   TRACT.  35 

of  variable  intensity  and  duration,  and  of  extensive  or 
limited  distribution."  Consciousness  may  be  present,  or  lost. 
Convulsions  are  also  termed  spasms;  but  this  term  is  usually 
applied  to  those  of  local  or  limited  distribution ;  as,  for 
instance,  the  muscles  supplied  by  one  nerve,  as  the  facial. 
Local  spasms  are  often  called  "  tics."  Convulsions  may  be 
tonic — i.  e.,  when  the  contraction  is  slow  and  continuous  ; 
and  clonic — i.  e.,  when  the  contractions  rapidly  and  alternately 
contract  and  relax.  A  lesion  limited  to  the  centres  of  a 
small  group  of  muscles  may  cause  a  general  convulsion  by 
an  overflow  of  energy.  In  such  cases  there  are  first  spasm  of 
the  muscles  governed  by  the  affected  centres,  and  then  a 
gradual  involvement  of  all  the  muscles  (see  Jacksonian 
Epilepsy). 

Contractures  and  contractions :  A  tonic  spasm  of  long 
duration  causes  a  contracture.  This  may  be  due  either  to 
irritation  of  the  motor  tract ;  to  a  destructive  lesion  of  the 
cortical  motor  neurons  and  consequent  overaction  of  the  spinal 
neurons,  due  to  the  deprivation  of  the  inhibitory  influence  of 
the  former ;  or  it  may  be  of  functional  origin,  as  in  hysteria. 

A  contracture  long  continued  often  causes  actual  organic 
shortening  of  the  muscle,  and  the  condition  is  then  termed  a 
contraction.  An  unequal  paralysis  of  antagonistic  muscles 
will  also  cause  a  contracture,  often  seen  in  poliomyelitis. 

Contractures  and  contractions — examination :  Contractures 
can  be  discovered  by  passively  flexing  and  extending  the 
limb,  when  an  abnormal  resistance  will  be  noted,  the  limb 
often  bending  like  a  piece  of  lead  pipe ;  by  supporting  the 
proximal  end  of  a  limb  and  allowing  the  distal  end  to  drop 
by  its  own  weight ;  and  by  noting  the  deformity  which  is 
produced  by  the  unequal  spasm  of  antagonistic  muscles,  one 
group  of  muscles  overpowering  their  antagonists  (Fig.  35). 
Functional  contractures,  unless  of  very  long  duration,  can  be 
differentiated  from  those  of  organic  cause  by  noticing  that 
they  disappear  while  under  the  influence  of  sleep  or  an 
anaesthetic. 

Athetoid  movements,  or  athetosis  :  Lesions  in  the  motor 
tract  sometimes  give  rise  to  a  peculiar  form  of  clonic  spasm 
which  causes  slow,  irregular  vermicular  movements  of  the 
fingers,  toes,  and  rarely  of  the  face,  which  are  termed  athetoid 


36  GENERAL  SYMPTOMATOLOGY. 

movements.  The  movements  are  independent  of  voluntary 
motion.  They  are  a  sequel  of  hemiplegia,  particularly  of  the 
form  that  occurs  in  childhood.  Often  the  paralysis  has 
almost  or  entirely  disappeared,  and  such  cases  may  be  mis- 
taken for  chorea.  A  careful  inquiry  will  usually  elicit  the 
history  of  a  previous  paralysis  (Fig.  10). 

Fibrillary  tremor :  A  fibrillary  tremor,  or  contraction,  is  an 
involuntary  contraction  of  small  numbers  of  muscle-fibres. 
They  are  seen  as  fine  wave-like  contractions  running  along 
the  muscle  in  whic^  they  occur.  Movement  of  the  part  is 
not  caused  by  them  They  occur  in  muscles  which  are  slowly 
atrophying  from  loss  of  neurotrophic  influence.  When  they 
do  not  occur  spontaneously  they  may  be  elicited  by  tapping 
the  muscle  witli  the  finger  or  some  other  mechanical  irrita- 
tion. They  are  usually  seen  in  chronic  poliomyelitis,  but 
may  occur  in  neurasthenia. 

By  tremor  we  mean  a  to-and-fro  movement  of  a  part  due 
to  a  more  or  less  rapid  involuntary  and  rhythmical  contraction 
of  antagonistic  muscles.  It  may  affect  the  muscles  of  the 
limbs,  or  neck,  face,  and  tongue. 

Tremor  is  probably  due  to  either  an  interruption  or  exag- 
geration of  the  impulses  as  they  pass  from  the  cortex  to  the 
muscle. 

Adamkiewicz  claims  that  tremor  is  due  to  disturbances  in 
the  equilibrium  of  the  two  innervating  stimuli — i.  e.,  a  cur- 
rent passing  down  the  posterior  columns  from  the  cerebellum 
which  keeps  the  muscles  in  a  state  of  tension  ;  and  one  pass- 
ing down  the  pryamidal  tract  which  conveys  voluntary  im- 
pulses and  regulates  the  degree  of  tension.  The  disturbance  in 
the  equilibrium  is  due  to  a  weakening  of  the  current  passing 
down  the  pyramidal  tract,  from  either  organic  or  functional 
causes. 

Tremors  are  divided  into  those  which  only  occur  during 
voluntary  movement  (intention-tremors) ;  those  which  are 
constant,  but  are  increased  by  voluntary  movement ;  and 
those  which  cease  for  a  time  or  diminish  after  voluntary 
movement. 

Tremor — examination :  If  a  tremor  is  not  apparent,  it  may 
be  discovered  by  making  the  patient  extend  the  arms  and 
hands  at  full  length,  or  perform  some  voluntary  act.     To  be 


OVERACTION  OF  THE  MOTOR    TRACT.  37 

Fig.  10. 


Examples  of  the  position  of  the  fingers  in  the  movements  of  athetosis  (Strumpell). 


38 


GENERAL  SYMPTOMA TOLOQ Y. 


sure  that  a  tremor  is  not  an  intention-tremor,  it  is  a  good 
plan  to  place  the  patient  in  a  recumbent  position.  Tremor 
of  the  tongue  is  tested  by  causing  it  to  be  protruded ;  that 
of  the  lips  and  face,  by  closing  the  eyes,  showing  the  teeth, 
or  whistling.  Care  must  be  taken  not  to  mistake  a  tremor  of 
the  head  due  to  the  neck-muscles  for  shaking  of  the  head  due 
to  tremor  of  the  trunk. 

Tremor  is  always  a  symptom,  although  at  times  it  is  ex- 
ceedingly difficult  to  ascertain  the  cause.  In  studying  such 
a  case  the  different  conditions  which  may  produce  tremor 
must  be  borne  in  mind.  With  the  exception  of  the  tremor 
of  multiple  sclerosis  and  paralysis  agitans,  all  tremors  in  the 
early  stages  of  the  trouble  are  of  the  intention-type  ;  but  as 
the  disease  progresses  they  may  become  constant.  Tremors 
due  to  organic  disease  are  usually  slow ;  those  of  functional 
or  toxic  origin  are  usually  rapid. 

The  following  table  gives  the  various  causes  of  tremor  and 
their  character : 


Cause. 

Type  of  Tkemor. 

Rapidity. 

■  Arsenic, 

Intention  in  early  stages ; 

Eapid. 

Lead, 

later  may  become  con- 

rr«^,-«    Alcohol, 

stant  ;  may  then  be  in- 

Toxic -1  Tot)acco, 

creased  by  exertion. 

Tea, 
Coffee. 
(■  Hysteria, 

Ibid. 

That  of  hysteria  some- 

Neuroses -<  Neurasthenia, 

times  is  slow ;  others 

(_  Exophthalmic  goitre. 

always  rapid. 

Senility. 

Ibid. 

Rapid. 

Heredity. 

Ibid. 

Rapid. 

Any  disease  of  brain,  spinal  cord, 

Ibid. 

May  be  slow  or  rapid, 

or  peripheral  nerves,   except- 

or both  combined. 

ing    multiple     sclerosis     and 

paralysis  agitans. 

Paralysis  agitans  (see  p.  323). 

Often  ceases    for    a    few 
seconds  after  muscular 
exertion. 

Slow. 

Multiple  sclerosis. 

Intention  only. 

Slow. 

Choreic  movements :  These  are  sudden,  jerking,  incoordi- 
nate, non-rhythmical,  and  non-purposive  movements  of  differ- 
ent groups  of  muscles.  They  usually  cease  during  voluntary 
effort.  Tics,  or  the  spasms  of  a  group  of  muscles  acting 
habitually  together,  as  of  the  face,  have  been  sometimes 
termed  choreic  movements ;  but  they  are  more  regular  and 
coordinate  than  the  true  movements  of  chorea. 


DESTRUCTIVE  LESIONS  OF  THE  MOTOR  TRACT.     39 

Forced  movements :  These  arc  movements  in  which  the 
patient  is  forced  against  his  will  to  move  in  a  certain  direc- 
tion, to  one  side,  forward  or  backward,  or  to  rotate. 

Associated  movements  are  seen  when  a  movement  of  a  non- 
paralyzed  limb  causes  a  movement  in  the  paralyzed  one ;  or, 
more  rarely,  in  cases  of  partial  paralysis  when  movements  of 
the  paralyzed  side  cause  movements  of  the  sound  limb. 

Symptoms   due  to  Destructive  Lesions  of  the  Motor 

Tract. 

Paralysis :  The  result  of  a  destructive  lesion  involving  the 
motor  tract  is  termed  paralysis.     If  the  function  is  not  en- 


FlG.   11. 


CU  represents  a  cell  in  the  motor  region  of  the  brain-cortex ;  PY  is  its  axon,  which 
forms  part  of  the  pyramidal  tract ;  SO  represents  a  cell  in  the  gray  matter  of  the 
cord  (anterior  horns);  PN,  its  axon,  forming  part  of  a  peripheral  nerve;  M, 
muscle.  A  lesion  destroying  CU,  or  any  part  of  the  tract  PY,  causes  a  central 
palsy ;  a  lesion  destroying  SO,  or  any  part  of  the  tract  PN,  a  peripheral  palsy. 

tirely  destroyed,  it  is  sometimes  called  paresis.     When  one 
limb  or  a  single  group  of  muscles  of  a  limb  is  affected  it  is 


40 


GENERA  L  SYMPTOM  A  TOL  OGY. 


called  monoplegia.  When  all  or  most  of  the  nmscles  of  one 
side  of  the  body  are  paralyzed  it  is  termed  hemiplegia.  Paral- 
ysis of  the  lower  limbs  is  known  as  paraplegia;  and  as 
diplegia  when  it  affects  corresponding  extremities  as  two 
arms,  two  legs,  or  all  four  limbs.  When  one  side  of  the  face 
and  the  limbs  of  the  opposite  side  are  paralyzed  we  speak  of 
an  alternate  or  crossed  paralysis.  If  contractures  are  present, 
the  paralysis  is  said  to  be  spastic. 

Paralysis — ^varieties :  Paralyses  are  divided  according  to  the 
portion  of  the  motor  tract  affected,  into  central,  in  which  some 
portion  of  the  primary  neuron  is  the  seat  of  the  lesion ;  and 
peripheral,  in  which  some  portion  of  the  peripheral  neuron  is 
diseased  (Fig.  11). 

Table    shoiving   differences    between  central    and    peripheral 

paralyses  : 


Nutrition  of  muscles. 

Tone  of  muscles. 

Electrical  reaction  (see 
Electricity). 

Reflexes. 


Disease  of  Peimaey  Neueon 
OE  Centeal. 


Good. 

Increased ;  muscles    usu- 
ally rigid  and  spastic. 
Same  as  normal  muscle. 


Increased. 


Disease    of    Secondaey 
Neueon  oe  Peeipheeal. 


Poor;  muscles  atro- 
phied. 

Diminished ;  muscles 
flaccid. 

Changed ;  either  quanti- 
tative decrease  or  re- 
action of  degeneration 
present. 

Diminished  or  lost. 


Paralysis — methods  of  examination  :  In  examining  a  case  of 
suspected  paralysis  it  is  important  to  remember  that  some- 
times muscular  weakness  may  be  caused  by  exhaustion  from 
some  acute  illness,  and  that  the  movements  of  a  limb  may  be 
restricted,  not  from  weakness  due  to  the  lesion  of  the  nervous 
system,  but  from  pain  caused  by  making  the  movement. 
This  is  often  seen  in  joint-inflammations.  Impairment  of 
motion  may  also  be  due  to  complete  or  partial  anchyloses. 

In  most  cases  the  existence  of  paralysis  is  obvious.  The 
inability  to  use  the  part,  if  an  entire  limb  is  paralyzed ;  or 
the  resultant  deformity  when  a  group  of  muscles  only  is 
involved  (due  to  the  unbalanced  action  of  antagonistic  mus- 
cles ;  for  example,  the  drooping  of  tlie  eyelid  in  the  paralysis 
of  the  motor  oculi  nerve),  is  at  once  apparent. 


DESTRUCTIVE  LESIONS  OF  THE  MOTOR   TRACT.      41 

However,  wlien  the  weakness  is  slight,  or  there  is  a  ques- 
tion of  diagnosis  from  the  conditions  above  mentioned,  cer- 
tain tests  are  useful.  From  our  knowledge  of  anatomy  Ave 
know  the  uses  of  each  muscle  ;  therefore,  to  detect  weakness, 
we  cause  the  patient  to  use  the  suspected  muscles,  comparing 
the  movements  with  those  of  the  opposite  side.  For  instance, 
if  the  muscles  of  the  face  are  being  examined,  we  make  the 
patient  wrinkle  the  forehead,  open  and  close  the  eyelids, 
smile,  whistle,  and  draw  the  mouth  from  side  to  side. 

Paralysis  of  the  soft  palate  can  be  detected  by  causing  the 
patient  to  open  the  mouth  and  make  the  sound  "ah."  If 
both  sides  are  paralyzed,  the  palate  will  be  seen  to  move  but 
slightly  or  not  at  all.  If  only  one  side  is  paralyzed,  the  palate 
will  be  drawn  upward  on  the  sound  side  only. 
.  Weakness  of  the  tongue  is  detected  by  noticing  if  it  is  pro- 
truded with  difficulty  or  to  one  side  ;  and  if,  when  protruded, 
it  cannot  be  kept  so  long.  Weakness  of  the  muscles  which 
move  the  eyeball  may  be  roughly  tested  by  covering  one  eye 
and  causing  the  patient  to  follow  the  finger  while  it  is  moved 
in  various  directions,  the  head,  of  course,  being  kept  fixed. 

Fig.  12. 


Hand  dynamometer. 


The  patient  may  also  complain  of  seeing  double,  or  diplopia. 
To  test  the  movements  of  the  iris,  we  notice  if  it  contracts 
when  a  bright  light  is  held  before  the  eye  and  dilates  when 
the  light  is  removed,  the  other  eye  being  kept  covered. 


42  GENERAL  SYMPTOMATOLOGY. 

The  arms  are  examined  by  causing  the  patient  to  contract 
the  muscle  while  we  apply  counterforce ;  by  having  him 
squeeze  your  hands  with  his ;  or  by  using  the  dynamometer 
(Fig.  1 2)  and  comparing  the  records  made.  If  a  leg  is  weak, 
it  is  dragged  as  the  patient  walks.  In  slight  cases  an  exces- 
sive wearing  of  the  toe  of  the  shoe  is  all  that  is  noticed. 

If  coma  is  present,  we  can  often  detect  paralysis  by  notic- 
ing the  less  resistance  with  which  the  limb  falls  when  allowed 
to  drop,  as  compared  with  the  other  side. 

Atrophy,  if  marked,  is  at  once  apparent.  Slight  degrees 
are  detected  by  noticing  that  the  muscles  are  more  flaccid 
than  normal  and  by  measuring.  To  measure,  we  select  a 
fixed  point,  as  the  anterior  iliac  spine,  from  which,  at  equal 
distances  on  each  side,  we  mark  a  number  of  points  ;  at  these 
points  we  take  the  circumference  of  the  limbs  and  compare 
the  results.  Valuable  information  is  also  obtained  by  using 
the  electrical  current  (see  Electricity). 

Symptoms  due  to  Irritative    Lesions  of   the    Sensory- 
Tract. 

Hyperaesthesia :  Irritation  of  the  sensory  tract  may  cause 
increased  sensibility  to  pain  (increased  sensibility  to  other 
forms  of  sensation  is  not  yet  capable  of  being  detected),  a 
condition  termed  hypercesthesia.  When  it  exists,  slighter 
stimuli  than  normal  should  cause  painful  or  disagreeable  sen- 
sations. Irritation  of  any  portion  of  the  sensory  tract  may 
produce  it. 

Pain :  This  is  another  expression  of  sensory  tract  irrita- 
tion. At  times  its  character  and  situation  may  be  of  diag- 
nostic value.  It  may  be  limited  to  the  distribution  of  a 
certain  nerve,  as  in  neuralgia  and  neuritis;  it  may  be  diffuse, 
as  in  cerebral  meningitis  or  brain-tumor. 

Dull  pains  arc  often  present  in  diseases  of  the  spinal  cord 
and  sometimes  in  neuritis.  Care  should  be  taken  not  to 
mistake  them  for  rheumatism.  Sharp,  shooting  pains  are 
characteristic  of  neuralgia  and  often  indicate  irritation  of  the 
posterior  nerve-roots,  as  in  meningitis  and  locomotor  ataxia. 
The  so-called  girdle-pain,  a  feeling  as  if  a  band  were  tied 
about  the  body,  also  indicates   nerve-root   irritation.     The 


DESTRUCTIVE  LESIONS  OF  THE  SENSORY  TRACT.    43 

pain  of  neuritis  may,  in  some  cases,  be  described  as  burning ; 
such  pain  is  known  as  '' cansalgia."  Irritative  lesions  of 
the  cortical  centres  may  cause  })ain  to  be  referred  to  the 
limbs.  Likewise,  diseased  parts  of  the  body  may  cause  pain 
to  be  referred  to  remote  parts,  if  the  nerv^e-supply  is  the  same, 
as  in  the  knee-pain  of  hip-joint  disease  ;  or  by  the  close  prox- 
imity of  the  centres,  as  headache  due  to  eye-strain,  where 
irritation  of  the  primary  visual  centres  causes  pain  in  the 
fifth  nerve  distribution.  Where  an  irritation  of  one  side 
of  the  body  is  felt  at  a  corresponding  point  on  the  other,  it 
is  termed  allochiria.  If  the  diseased  part  is  superficial,  ten- 
derness is  often  also  present,  as  in  neuritis  and  meningo- 
myelitis  dependent  on  disease  of  the  vertebrae. 

Parsesthesia :  Perverted  or  abnormal  sensations,  except- 
ing pain,  such  as  tinglings,  crawlings,  burning,  numbness, 
etc.,  are  called  parsesthesise.  They  may  be  due  to  organic 
nerve-disease  of  any  portion  of  the  sensory  tract  from  the 
cortex  to  the  periphery ;  or  they  may  have  a  subjective  origin. 
When  the  touch  of  one  point  is  felt  as  two  or  more  it  is 
termed  polycesthesia. 

SYMPTOMS  DUE  TO  DESTRUCTIVE  LESIONS  OF  THE 
SENSORY  TRACT. 

These  symptoms  differ  according  to  which  pathway  is  dis- 
eased— i.  e.,  that  for  touch,  pain,  temperature,  or  muscle 
sense.  They  may  be  all  damaged,  or  one  or  more  may  be 
and  the  others  not.  Sensory  fibres  often  preserve  their  func- 
tions when  damaged  to  an  extent  that  would  destroy  the 
functions  of  the  motor  fibres,  and  they  recover  their  function, 
when  lost,  sooner  than  do  the  motor  fibres.  Loss  of  sensa- 
tion may  be  due  to  either  organic  or  functional  disease. 

Anaesthesia :  Strictly  speaking,  this  word  means  loss  of 
tactile  sensibility,  but  is  often  loosely  used  to  include  loss  of 
pain-sense.  When  the  loss  involves  one-half  of  the  body  it 
is  termed  Jiemiancesthesia.  The  face  may  sometimes  be 
spared.  When  complete,  the  entire  lateral  half  of  the  body, 
including  mucous  membranes  and  special  senses,  is  involved. 
If  of  organic  origin,  it  means  the  existence  of  a  lesion  in  the 
tract  between  the  upper  portion  of  the  pons  and  the  cortex  of 


44  GENERAL  SYMPTOMATOLOGY. 

the  opposite  side.  Crossed  heiniansesthesia  means  anaesthesia 
of  one  side  of  the  body  and  of  the  opposite  side  of  the  face. 
It  is  due  to  a  lesion  in  the  pons.  Hemiansesthesia  often 
occurs  in  hysteria.  Irregular  areas  of  ansesthesia  scattered 
over  the  body  and  limbs  also  occur.  They  are  usually  met 
with  in  hysteria ;  sometimes  in  locomotor  ataxia. 

Analgesia  means  loss  of  sensibility  to  pain.  As  has  been 
said,  it  may  occur  without  loss  of  tactile  sensibility,  especially 
in  diseases  of  the  cord  in  which  the  pathways  for  touch  and 
pain  are  widely  separated.  Loss  of  pain-sense  in  one  lateral 
half  of  the  body  is  called  hemianalgesia.  In  some  diseases 
(notably  locomotor  ataxia)  we  may  have,  instead  of  absolute 
loss,  a  delay  in  the  transmission  of  a  sensation,  so  that  it  is 
not  felt  for  an  appreciable  interval  after  the  reception  of  the 
stimulus.  It  should  also  be  noted  in  testing  both  pain-  and 
tactile  sense  whether  the  patient  can  correctly  localize  the 
point  touched. 

Temperature-sense :  When  lost  this  is  usually  associated 
with  loss  of  sensibility  to  pain,  the  two  pathways  being  prob- 
ably closely  related  (see  Sensory  Tract).  It  occurs  either  as 
an  inabihty  to  tell  hot  from  cold ;  or  hot  objects  may  give 
cold  sensations,  cold  being  appreciated,  or  vice  vey^sa.  Some- 
times great  differences  can  be  recognized  while  slighter  ones 
cannot.  In  some  affections  of  the  nervous  system  (notably 
in  syringomyelia,  less  commonly  in  diseases  affecting  the  pos- 
terior nerve-roots  as  vertebral  caries,  cervical  pachymeningi- 
tis, tabes,  spinal  tremor,  myelitis,  multiple  sclerosis,  and  also 
in  disease  of  the  peripheral  nerves  and  hysteria)  there  may 
be  loss  of  pain-  and  temperature-sense  with  preservation  of 
the  sense  of  touch.  When  the  cord  is  affected,  as  in  syringo- 
myelia, this  is  probably  due  to  the  fact  that  fibres  conducting 
pain-  and  temperature-sensations  cross  in  the  posterior  com- 
missure to  form  Gower's  tract,  and  consequently  would  be 
destroyed  by  a  lesion  destroying  the  central  gray  matter, 
while  the  fibres  conducting  tactile  sensations  pass  up  the  pos- 
terior columns  and  escape.  The  explanation  as  to  why  this 
occurs  in  root-lesions  is  not  so  clear.  It  may  be  due  to  the 
fibres  conducting  tactile  sensations  being  less  vulnerable  to 
pressure  than  those  conducting  pain-  and  temperature-sen- 
sations. 


SENSORY  LOSS.  45 

Muscle-sense :  This  includes  a  perception  of  passive  and 
active  movements  ;  of  the  position  of  the  limbs  ;  and  of  press- 
ure and  resistance. 

Stereognostic  seiiHe  is  the  name  given  to  memories  preserved 
in  the  central  cortex  (parietal  lobe)  of  the  characteristics  of 
objects  by  which  we  are  enabled  to  recognize  them  without 
seeing  them.  Thus  when  a  blindfolded  jierson  recognizes  a 
dollar  placed  in  the  hand  he  does  so  by  his  memory  of  the 
I)eculiar  feel,  weight,  etc.,  of  previous  dollars.  This  sense 
depends,  according  to  Sailer,  upon  "an  intricate  correlation 
of  tactile,  position,  pressure,  localization,  and  temperature 
perceptions  and  its  interpretation  by  the  higher  psychic  cen- 
tres." The  most  important  element  seems  to  be  the  muscle- 
sense,  for  it  has  been  found  impaired  more  or  less  in  the  re- 
ported cases,  while  other  forms  of  sensibility  may  be  pre- 
served. The  stereognostic  sense  has  been  found  impaired 
most  frequently  in  hemiplegia..  Its  impairment  is  termed 
astereognosis. 

Sensory  Loss — Methods  of  Examination. 

Before  applying  the  various  tests  used  to  detect  sensory 
paralysis  the  patient  should  be  blindfolded. 

Anaesthesia  is  tested  for  by  touching  the  part  with  a  light 
object,  such  as  a  piece  of  absorbent  cotton.  This  may,  begin- 
Bing  at  the  face,  be  stroked  down  the  body  to  the  feet,  telling 
the  patient  to  advise  you  as  soon  as  he  does  not  feel  it  and  then 
marking  the  spot.  In  this  way  the  anaesthetic  areas,  if  any, 
may  be  mapped  out.  This  procedure  should  be  repeated, 
changing  the  direction  of  the  stroking  to  confirm  the  correct- 
ness of  the  observation. 

Analgesia  is  discovered  by  pricking  the  skin  and  mucuos 
membrane  with  a  pin,  going  over  the  body  systematically,  as 
in  the  test  for  anaesthesia,  and  instructing  the  patient  to 
inform  you  as  soon  as  he  feels  it,  or  else  to  count  each  time 
he  feels  the  prick.  If  he  misses  a  count,  we  know  that  the 
patient  does  not  feel  it.  It  should  also  be  noticed  if  the 
patient  winces,  or  if  there  is  delayed  transmission,  indicated 
by  the  announcing  of  the  sensation  being  felt  several  seconds 
after  the  stimulus  is  used. 


46  GENERAL  SYMPTOMATOLOGY. 

Loss  of  temperature-sense  is  discovered  by  the  alternate  use 
of  test-tubes  filled  with  hot  and  cold  water,  or  by  painting 
ether  over  the  skin. 

If  loss  of  muscle-sense  is  suspected,  we  test  the  perception 
of  passive  moments  by  taking  the  joint  firmly  between  the 
hands  and  moving  it  slightly,  ascertaining  if  the  patient 
knows  what  you  do.  Or  move  a  finger  of  one  hand  gently, 
letting  the  patient  perform  the  same  movement  with  the 
finger  of  tlie  opposite  hand.  Movement  of  the  smaller  joints 
should  always  be  tested  first. 

Perception  of  pressure  and  resistance  may  be  tested  by  using 
rubber  balls  of  the  same  size  filled  with  different  quantities 
of  shot.  These  are  placed  on  the  hand  or  leg,  and  the 
patient  is  asked  to  determine  which  is  the  heavier. 

Knowledge  of  the  position  of  parts  is  determined  by  placing 
a  limb  in  a  certain  position  and  asking  the  patient  to  place 
the  opposite  one  in  the  same  position.  The  p)resence  or  ab- 
sence of  the  stereognostic  sense  is  determined  by  placing  familiar 
objects  in  the  hand  and  requesting  the  patient  to  name  them ; 
if  he  cannot,  there  is  loss  of  the  sense. 

Incoordination —  Ataxia. 

Definition :  For  a  muscular  movement  to  be  performed 
in  a  regular,  smooth,  and  co5rdinate  manner,  it  is  necessary 
that  the  contraction  of  each  muscle  concerned  in  the  move- 
ment, and  also  that  of  the  antagonists  of  the  muscles,  be 
accurately  proportioned  in  force  and  time.  For  example, 
when  we  use  the  flexor  muscles  of  a  limb,  the  extensors  act 
as  a  balance;  otherwise  all  movements  would  be  quick  and 
jerky. 

For  the  proper  performance  of  this  function,  sensations 
travel  from  the  muscles,  articular  surfaces,  and  tendons 
(muscle-sense),  and  to  some  extent  from  the  skin  (tactile 
sense)  up  through  the  posterior  columns  and  direct  cerebellar 
tract  to  the  cerebellum,  and  thence  to  the  sensori-motor  region 
of  the  cortex.  A  lesion  so  situated  as  to  prevent  these  sensa- 
tions reaching  the  cortex  will  produce  incoordination.  Hence 
lesions  of  the  brain,  cord,  or  peripheral  nerves  may  produce 
this   symptom,   which   is   usnally   known    as  ataxia.     More 


JNCO  ORDINA  TION—A  TA  XI A .  47 

properly  the  use  of  the  term  ataxia  is  only  applied  to  that 
form  of  incoordination  due  to  spinal  cord  disease. 

Ataxia,  may  also  be  present  during  apparent  rest,  and  is 
then  called  static  ataxia.  To  maintain  any  ])osture,  coordi- 
nated muscular  movements  are  necessary.  When  this  func- 
tion is  deranged  swaying  movements  of  the  body,  or  irregular 
movements  of  the  limbs,  become  manifest. 

Incoordination — cerebral :  Cortical  lesions,  especially  of  the 
parietal  lobes,  may  produce  more  or  less  disturbance  of  the 
muscle-sense  and  consequent  ataxia.  This  is  usually  asso- 
ciated with  hemiplegia  and  is  known  as  post-hemiplegic 
ataxia.  The  incoordination  which  sometimes  occurs  in  ^2^8- 
teria  is  also  of  cortical  origin. 

Incoordination — cerebellar :  Lesions  of  the  cerebellum  espe- 
cially of  the  middle  lobe,  cause  a  form  of  incoordination, 
commonly  termed  titubation.  The  gait  resembles  that  of 
alcoholic  intoxication ;  the  patient  is  unable  to  walk  in  a 
straight  line,  and  there  is  often  a  tendency  to  fall  always  in 
the  same  direction,  either  right,  left,  or  backward,  as  the  case 
may  be.  The  arms  are  not  affected  so  commonly  as  the  legs. 
Similar  disturbances  sometimes  occur  in  disease  of  the  pons 
or  medulla  in  which  the  fillet  is  involved. 

Incoordination — spinal  cord  and  peripheral  nerves  :  In  the 
great  majority  of  cases  this  is  due  to  disease,  either  of  the 
posterior  median  columns,  posterior  nerve-roots,  or  both. 
The  patient  walks  in  such  cases,  if  the  symptom  is  marked, 
with  his  eyes  fixed  on  the  ground  ;  the  legs  wide  apart ;  lifts 
the  feet  higher  than  normal  and  throws  them  forward  in  a 
jerky  manner.  In  some  cases  of  multiple  peripheral  neuritis, 
if  the  paralysis  is  not  marked,  incoordination  is  present. 

Incoordination — examination  :  The  existence  of  static  ataxia 
is  discovered  by  causing  the  patient  to  hold  the  limbs  in  some 
fixed  position  without  support,  when  the  movements  described 
will  be  seen ;  or  to  stand  erect  with  the  feet  close  together 
and  the  eyes  closed.  If  the  symptom  is  present,  the  patient 
will  sway  violently  to  and  fro  and  may  fall.  This  is  known 
as  the  Romberg  sign. 

Dynamic  ataxia  of  the  lower  limbs  is  tested  by  making 
the  patient  walk  forward  and  backward  with  the  eyes  first 
open   and  then  closed ;  turn  suddenly  while  walking ;  raise 


48  GENERAL  SYMPTOMATOLOGY. 

himself  upon   his  toes  with  the  eyes  closed ;  and  stand  on 
one  leg. 

The  upper  limbs  are  studied  by  having  the  patient  touch 
the  end  of  his  nose  with  his  finger;  pick  up  small  objects; 
button  his  clothes  ;  and  after  separation  of  his  arms  by  making 
him  endeavor  to  bring  the  points  of  his  fingers  together.  In- 
ability to  perform  these  movements  will  indicate  ataxia. 
Degrees  of  incoordination  so  slight  as  not  to  be  noticeable  in 
the  gait  are  detected  by  examining  for  the  Romberg  symptom 
with  the  feet  and  legs  of  the  patient  bare ;  in  the  effort  to 
maintain  his  position  contractions  of  the  muscles  of  the  legs 
Avill  be  caused,  which  can  be  detected  by  watching  the  ten- 
dons about  the  ankles. 

Examination  of  Special  Senses. 

Sight :  In  diseases  of  the  nervous  system  the  sense  of  sight 
may  be  variously  affected,  the  causes  of  which  are  either 
functional  or  organic.  When  there  is  a  subnormal  acuteness 
of  vision  due  neither  to  refractive  error  nor  visible  organic 
lesion,  we  term  the  condition  amblyopia. 

Amaurosis  is  a  word  sometimes  used  to  express  blindness. 
Hemianopsia  denotes  blindness  of  one-half  the  visual  field. 
Homonymous  hemianopsia  indicates  l)lindness  of  the  outer 
half  of  one  and  the  inner  half  of  the  other  field  of  vision. 
When  we  wish  to  indicate  which  side  of  the  retina  is  blind 
we  nse  the  word  hemiopia  :  thus,  a  right-sided  hemianopsia 
would  be  a  left-sided  hemiopia. 

In  all  doubtful  cases  the  eye  should  be  examined  by  a 
skilled  ophthalmologist,  the  presence  of  optic  neuritis  and 
atrophy,  primary  and  secondary,  being  valuable  symptoms  of 
many  organic  diseases  of  the  nervous  system.  The  existence 
of  hemianopsia — i.  e.,  i)]indness  of  one-half  the  visual  field 
— can  be  roughly  determined  by  sitting  the  patient  in  front 
of  you  with  one  eye  blindfolded,  and  tell  him  to  look  steadily 
at  the  end  of  your  nose  with  the  other.  A  white  object  is 
then  brought  from  different  points  of  the  periphery  toward 
your  nose,  and  the  patient  is  instructed  to  say  when  he  sees  it. 
If  he  does  not,  that  part  of  the  field  is  blind. 

The    existence   of   refractive    errors,  a    common    cause   of 


THE  REFLEXES.  49 

headache,  may  be  surmised  if  the  eyes  water  and  letters  run 
together  after  reading  a  while.  The  presence  or  absence  of 
exophthalmos  should  also  be  noted. 

Hearing  :  This,  to  be  accurately  tested,  also  re(£uires  the  ser- 
vices of  a  specialist.  Tiie  existence  of  tinnitus  should  be  in- 
quired for.  The  acuity  of  hearing  can  be  determined  by  blind- 
folding the  patient  and  covering  one  ear.  A  watch  is  then 
held  some  distance  from  the  other  ear  and  made  to  approach 
toward  it,  the  patient  signifying  when  he  hears  the  tick. 
Watches,  of  course,  differ  in  the  loudness  of  tiu'ir  tick;  the 
normal  distance  being  from  two  to  four  feet.  In  order  to 
determine  whether  the  deafness,  if  any,  is  due  to  disease  of 
the  nerve  or  of  the  middle  ear,  we  use  a  large  tuning-fork 
(note  C),  and  note  whether  the  sound  is  heard  best  when  it  is 
held  at  a  distance  from  the  ear  or  when  placed  on  the  top  of 
the  head.  If  aerial  conduction  is  the  better,  the  nerve  is  dis- 
eased ;  if  the  sound  by  bone-conduc^tion  is  more  distinct,  the 
cause  of  the  deafness  exists  in  the  middle  ear. 

Smell:  Care  should  be  taken  in  testing  smell  not  to  use 
odors  which  are  irritative,  as  ammonia.  With  one  nostril 
closed  ^ve  test  the  other  with  musk,  violets,  or  some  perfume 
of  like  nature.  The  possibility  of  catarrhal  trouble  causing 
loss  of  smell  must  always  be  considered. 

Taste  :  In  testing  taste  we  use  a  bitter  substance,  as  qui- 
nine ;  a  sweet  one,  as  sugar ;  and  a  sour  one,  as  vinegar. 
The  bitter  should  be  used  last.  The  patient  keeps  the  tongue 
protruded,  while  one  of  the  solutions  is  painted,  with  a  camel's 
hair  brush,  on  each  side  of  the  tongue,  first  posteriorly  and 
then  anteriorly.  The  patient  can  indicate  if  he  tastes  the 
solution  by  pointing  to  the  name,  which  has  previously  been 
written  on  paper.  Under  no  circumstances  should  the  tongue 
be  withdrawn  into  the  mouth  until  the  test  is  completed.  To 
decide  if  there  is  complete  loss  of  the  sense,  it  should  also  be 
tested  on  the  lips,  the  inner  surfaces  of  the  mouth,  the  palate, 
the  pharynx,  the  epiglottis,  and,  when  possible,  the  larynx. 

THE  REFLEXES. 

To  cause  a  reflex  action  there  are  necessary  an  afferent 
nerve,  either  an  ordinary  sensory  or  the  special  excito-reflex 

^— N.  n. 


50 


GENERAL  SYMPTOMATOLOGY. 


nerve  supplied  to  the  viscera ;  an  efferent  or  inotor  nerve  ;  and 
the  cells  (reflex  centre)  in  the  gray  matter  of  the  cord  or 
medulla  to  which  the  alferent  nerve  runs  and  from  which  the 
efferent  starts.  This  mechanism  is  controlled  by  the  higher 
cortical  (motor)  cells,  which  exercise  their  influence  through 
the  pyramidal  tract  (Fig.  13). 

Fig.  13. 


-^ — ^^ 


Diagram  showing  reflex  arc  and  inhibitory  fibre,  and  some  of  the  diseases  which 
exaggerate  or  destroy  the  knee-jerk. 

Reflexes  are  o?  four  hinds :  the  skin,  or  superficial ;  tendi- 
nous and  muscular,  or  deep  ;  visceral,  and  idiopathic  muscular. 

When  any  of  the  components  of  the  reflex  arc — viz.,  affer- 
ent nerve,  cells  in  gray  matter,  efferent  nerve — are  damaged 
the  refliexes  under  the  control  of  that  particular  arc  are 
lessened  or  absent.  An  irritative  lesion  of  the  pyramidal 
tract  will  sometimes,  by  increasing  inhibition,  cause  a  reflex  to 
be  diminished  or  absent.  If  the  inhibitory  influence  of  the 
brain  is  removed,  as  by  a  destructive  lesion  of  the  pyramidal 
tract,  the  reflexes  are  increased. 

The  Skin-reflexes. 
These  are  produced  by  scratching,  irritating,  or  tickling  the 
skin,  which,  if  the  reflex  is  present,  causes  a  contraction  of 
the  muscles  near  the  irritated  part. 


THE  DEEP  OR  MUSCLE-  AND   TENDON-REFLEXES.    51 

The  most  important  are  : 

The  plantar  reflex  consists  of  a  flexion  of  the  toes  upon  the 
metatarsus  and  a  quick,  involuntary  jeriving  of  the  foot  and 
leg  when  the  sole  of  the  foot  is  irritated.  In  making  this 
test  the  leg  should  be  in  such  a  position  as  to  insure  muscular 
relaxation.  M.  J.  Babinski  has  recently  called  attention  to 
the  fact,  which  has  been  confirmed  by  Collier  and  others,  that 
when  there  are  lesions  of  the  pyramidal  tract  the  toes  are 
extended  upon  the  metatarsus,  instead  of  flexed.  This  does 
not  hold  good  in  infants. 

The  cremasteric  reflex  is  caused  by  irritating  the  skin  on 
the  inside  of  the  thigh,  when  a  drawing  up  of  the  testicle 
will  be  seen. 

The  abdominal  reflex  consists  of  a  contraction  of  the  rectus 
muscle  of  the  abdomen  when  the  side  of  the  abdomen  is 
scratched. 

The  lid-reflex  consists  of  closure  of  the  eye  when  the  con- 
junctiva or  retina  is  irritated. 

The  pupillary  skin-reflex  consists  of  a  dilatation  of  the 
pupil  when  the  skin  on  the  side  of  the  neck  is  pinched. 

Those  which  are  of  not  so  constant  occurrence  are  : 

The  epigastric  reflex,  j)roduced  by  irritating  the  skin  of 
the  lower  part  and  side  of  the  thorax.  This  causes  contrac- 
tion of  the  upper  fibres  of  the  rectus  muscle. 

The  erector  spinae  reflex  consists  of  contraction  of  some  of 
the  fibres  of  the  erector  spin?e,  caused  by  irritation  of  the  skin 
along  its  outer  edge. 

The  scapular  reflex  consists  of  a  contraction  of  the  scapular 
muscles  when  the  skin  over  them  is  irritated. 

The  palmar  reflex  is  produced  by  irritating '  the  palms  of 
the  hand,  when  a  jerking  away  of  the  arm  and  closing  the 
hand  will  be  seen. 

The  Deep  or  Muscle-  and  Tendon-reflexes. 

Some  of  these  are  not  found  in  healthy  individuals,  only 
being  present  when   reflex  activity  is  increased. 

The  knee-jerk,  or  patellar  tendon-reflex,  is  the  most  constant, 
but  rarely  it  is  not  present  in  apparently  healthy  individuals. 


52  .  GENERAL  SYMPTOMATOLOGY. 

It  consists  of  a  sucklen  contraction  of  the  quadriceps  femoris 
and  vastus  intern  us  and  externus  mnscles,  produced  by  strik- 
ing the  patellar  tendon  while  the  leg  hangs  loosely  at  a  right 
angle  to  the  thigh  ;  for  instance,  the  leg  being  crossed  over  the 
other.  This  may  also  be  produced  if  the  lower  part  of  the 
muscle  is  struck.  It  may  be  increased,  or  at  times  brought 
into  activity  when  absent — called  reinforcement — if  at  the 
time  the  tendon  is  struck  the  patient  performs  some  volun- 
tary muscular  movement,  such  as  tightly  closing  the  hands 
or  pulling  on  his  clasped  fingers.  Reinforcement  is  not  pos- 
sible if  the  absence  of  the  reflex  is  due  to  organic  disease. 

Ankle-clonus  is  caused  by  grasping  the  extended  leg  under 
the  calf  with  one  hand  and  suddenly  making  dorsal  flexion 
of  the  foot  with  the  other.  When  it  is  present  there  will  be 
seen  a  series  of  rapid  contractions  of  the  calf-muscles  causing 
to-and-fro  movements  of  the  foot.  This  reflex  is  never 
present  in  health. 

The  tendo  Achillis,  or  ankle-jerk,  is  elicited  by  striking  the 
tendo  Achillis,  when  the  calf-muscles  contract,  causing  a 
plantar  flexion  of  the  foot.  It  may  be  present  when  the 
knee-jerk  is  absent,  or  vice  versa. 

The  wrist-jerk  is  elicited  by  striking  the  flexor  tendons  at 
the  wrist,  made  prominent  by  passive  extension  of  the  hand, 
the  wrist  of  the  patient  being  supported  by  the  examiner. 
Flexion  of  the  hand  takes  place. 

The  elbow-  or  triceps-jerk  consists  in  a  contraction  of  the 
triceps  muscle  when  its  tendon  is  struck  just  above  the 
elbow-joint,  the  forearm  hanging  loosely  at  a  right  angle  to 
the  supported  arm. 

The  biceps  and  supinator  jerk  is  obtained  by  striking  the 
lower  end  of  the  radius,  the  elbow  being  partly  flexed  at  the 
time.     Contraction  of  the  biceps  results. 

The  jaw-jerk  is  produced  by  causing  the  patient  to  set  with 
the  mouth  partly  o])en  with  a  ruler  or  something  similar  laid 
across  the  lower  teeth.  When  this  is  struck  the  masseter 
muscles  contract  and  the  mouth  closes. 

The  wrist-,  elbow-,  and  jaw-jerks  are  rarely  found  in  health. 
If  well  marked,  they  always  indicate  disease. 

A  muscle-jerk  is  obtained  by  striking  the  stretched  muscle, 
when  certain  or  all  of  the  fibres  contract.     It  may  be  present 


THE   VISCERAL  REFLEXES. 


53 


or  increased  in  di.seasos  in  which 
the  tendon-reflexes  are  absent; 
for  instance,  in  chronic  poliomye- 
litis. 

The  Visceral  Reflexes. 

The  eye :  Important  reflexes 
are  discovered  by  examining  the 
eyes.  The  light-reB^ex  is  pro- 
duced by  throwing  a  bright  light 
into  the  eye,  when  the  pupil  con- 
tracts, to  dilate  again  when  the 
light  is  removed.  The  accommo- 
dation-reflex is  brought  out  by 
causing  the  patient  to  look  at  a 
near  and  then  at  a  far  object;  in 
the  former  case  the  pupil  dilates ; 
and  contracts  in  the  latter.  The 
other  eye  should  be  covered. 
When  the  light-reflex  is  lost  and 
the  accommodation- reflex  remains 
we  have  what  is  known  as  the 
Argyll- Moberf son  pujyil. 

The  reflexes  of  the  bladder,  rec- 
tum, and  sexual  apparatus  :  Urina- 
tion and  defecation  are  reflex  acts, 
under  the  control  of  the  higher 
centres.  If  the  inhibitory  influ- 
ence is  removed,  and  voluntary 
control  over  the  sphincters  is  lost, 
urine  and  fseces  are  expelled  as 
soon  as  the  bladder  or  rectum  is 
full.  This  condition  is  seen  to 
greater  or  less  degree  whenever 
the  function  of  the  pyramidal 
tracts  is  interfered  with.  If  this 
condition  persists,  weakness  of  the 
detrusor  muscles  occurs  after  a 
time  and  the  bladder  is  not  com- 


FiG.  14. 


Diagram  iUustrating  the  inner- 
vation of  the  bladder  and  the 
effect  of  lesions  in  various 
parts  of  the  spinal  cord  upon 
the  function  of  micturition.  A 
lesion,  ^1,  which  interrupts  the 
voluntary  path  to  the  bladder- 
centre  in  the  sacral  cord,  causes 
incontinence  of  urine.  When  a 
sufficient  quantity  of  urine  ac- 
cumulates in  the  "bladder  there 
occur  a  reflex  contraction  of 
the  detrusor  and  a  relaxation 
of  the  sphincter.  The  sensory 
path  from  the  cord  to  the  brain 
being  uninvolved,  the  patient 
is  conscious  of  the  process,  but 
cannot  exercise  voluntary  con- 
trol over  it.  With  a  lesion,  B, 
which  involves  also  the  sensory 
path,  the  patient  is  unconscious 
of  the  filling  and  reflex  empty- 
ing of  the  bladder.  A  lesion, 
C,  which  causes  destruction  of 
the  sacral  reflex  centre  of  the 
bladder  causes  continuous 
dribbling  of  urine,  and  not  its 
automatic  expulsion  at  inter- 
vals (Herter). 


54  GENERAL  SYMPTOMATOLOGY. 

pletely  emptied.  If,  in  addition  to  the  preceding  conditions, 
the  tone  of  the  compressor  urethrce  nmscle  is  intact,  there  fol- 
lows retention  of  urine  until  the  bladder-distention  is  suffi- 
cient to  overcome  this  tone.  Thus  we  have  the  incontinence 
of  overflow. 

If  any  of  the  components  of  the  reflex  are  involved,  incon- 
tinence also  takes  place. 

If  the  motor-  part  is  diseased,  the  sphincters  are  relaxed. 

In  the  case  of  the  rectum  this  condition  can  be  diiferenti- 
ated  from  the  incontinence  due  to  loss  of  inhibition  by  intro- 
ducing the  finger  into  the  rectum.  In  the  former  case  the 
sphincter  will  be  found  relaxed  ;  in  the  latter,  it  grasps  the 
finger  firmly. 

When  complete  j)aralysis  is  not  present  there  is  difficulty 
in  starting  the  stream  of  urine,  or  there  may  be  obstinate 
constipation. 

Wlien  the  sensory  pjcirt  of  the  arc  is  damaged  the  patient  is 
unaware  that  the  bladder  or  rectum  is  full. 

Damage  to  the  reflex  arc  governing  the  genital  functions 
causes  loss  of  the  power  of  erection  of  the  penis  and  loss  of 
desire.  Removal  of  the  inhibitory  influence  may  produce 
priapism.  The  reflex  centres  of  these  functions  are  in  close 
proximity.  The  location  in  the  cord  of  all  of  the  various 
reflex  centres  and  their  localizing  significance  will  be  found 
under  Localization  in  the  Spinal  Cord. 

Idiopathic  Muscle -reflex. 

Paradoxical  contraction  consists  of  a  tonic  contraction  of  the 
anterior  tibial  muscles  produced  by  suddenly  flexing  the  foot 
on  the  leg,  thus  shortening  the  muscle.  Its  occurrence  is 
always  pathological. 

SYMPTOMS  DUE  TO  TROPHIC,  VASOMOTOR,  AND  SECRE- 
TORY DISTURBANCES. 

Trophic  disturbances  consist  of  hypertrophy  or  atrophy  of 
muscles ;  of  cutaneous,  osseous,  and  mucous  tissues ;  joint- 
afFections,  known  as  arthropathies ;  and  various  skin-eruptions 
as  herpes,  pigmentation,  alopecia,  and  bedsores. 

Vaso-motor  symptoms  are  pallor  and  coolness  of  the  skin, 


SECRETORY  DISTURBANCES.  55 

due  to  spasm  and  congestion  (arterial  or  venons);  and  nedema, 
due  to  relaxation  of  the  bloodvessels.  There  may  be  an  un- 
steadiness of  action  of  the  vaso-motors  ;  dilating  and  con- 
tracting in  an  irregular  way,  they  cause  various  flushings  and 
localized  oedemas  (angioneurotic  oedema),  a  condition  known 
as  vaso-motor  ataxia. 

Secretory  disturbances  consist  of  increase  or  diminution  of 
glandular  secretions,  as  excessive  sweating,  or  hyperidrosis  ; 
excessive  dryness,  or  anidrosis.  There  may  be  peculiar  odors 
or  colors  of  the  secretion. 


CHAPTER   IV. 

GENERAL  THERAPEUTIC   MEASURES. 
ELECTRICITY. 

Physics. 

Potential :  The  laws  which  govern  the  electrical  current  are 
very  similar  to  those  which  govern  the  flow  of  water.  If  we 
have  two  vessels  of  water  one  above  the  other  and  connected 
by  a  pipe,  the  fluid  in  the  higher  one  will  endeavor  to  get  to 
the  lower  ;  the  water  in  so  doing  will  exert  force  and  conse- 
quently a  ecvpacity  to  do  work,  which  is  called  its  potential. 
The  fluid  in  the  lower  vessel  would  also  endeavor  to  reach  a 
lower  level  which  is  ultimately  the  level  of  the  sea,  and  in  so 
doing  Avould  exert  force,  but  not  so  much  as  that  exerted 
by  the  higher  body  of  water.  The  sea-level  would  be  zero 
potential.  The  difference  in  the  force  exerted  by  these  two 
bodies  of  water  would  be  their  difference  in  potential. 

By  means  of  certain  agencies — viz.,  friction,  chemical  action, 
etc. — electricity  is  separated  into  positive  and  negative  electric- 
ity, the  positive  being  of  higher  potential  than  the  negative  ; 
these  tend  to  Iiecome  united,  that  of  the  higher  potential 
tending  to  flow  toward  the  lower,  just  as  the  fluid  in  the 
higher  vessel  tends  to  flow  toward  the  lower ;  and  this  ten- 
dency, when  the  conditions  are  favorable,  causes  an  electrical 
current.     The  zero  point  of  electrical  potential  is  the  earth. 

The  volt :  The  force  which  starts  the  column  of  water 
flowing  is  that  of  gravity ;  that  which  causes  the  electrical 
current  to  flow  is  termed  the  electro-motive  force  (E.  31.  F.), 
and  the  xnit  of  measiirement  of  such  force  is  the  volt. 

The  ohm :  Certain  substances  are  much  more  pervious  to 
the  passage  of  water  than  others  ;  so  with  the  electrical  cur- 
rent ;  substances  through  which  the  current  will  flow  with 
facility  are  known  as  conductors.     In  the  order  of  their  rela- 

56 


ELECTRICITY.  57 

tive  value  they  are  the  metals  ;  charcoal ;  plumbago ;  dilute 
acids;  saline  solutions;  water;  living  animals,  and  flame. 
Those  which  do  not  permit  its  free  passage  are  called  insula- 
tors, or  non-conductors.  They  are  rubber  ;  silk  ;  glass  ;  wax  ; 
sulphur ;  resins ;  shellac,  and  dry  air.  As  the  water  flows 
through  the  pipe  it  meets  with  resistance  ;  so  does  the  electri- 
cal current,  as  it  flows  through  the  conductor,  and  this  resist- 
ance, similar  to  that  which  water  would  experience,  will 
depend  on  tlie  length,  composition,  and  area  of  cross-section 
of  the  conductor — i.  e.,  a  current  passing  a  sliort  distance 
through  a  good  conductor  with  a  large  area  of  cross-section 
will  meet  with  less  resistance  than  will  a  current  subject  to 
opposite  conditions.     The  unit  of  resistance  is  the  ohm. 

The  ampere :  The  actual  current-strength  (C)  depends  on 
Ohm's  law — viz.,  the  current-strength  is  equal  to  the  E.  M.  F. 

Q  =zz  — ^— ^ — '  |.      Current-strength 

is  measured  in  amperes ;  and  in  medicine  we  use  the  one- 
thousandth  part  of  an  ampere,  or  a  milliamphr. 

As  water  may  be  confined,  so  by  means  of  insulators  can 
electricity.     It  is  then  said  to  be  static. 

The  electric  aparatus  used  in  medicine  is  of  three  kinds — 
viz.,  static,  gcdvanic,  and  faradic.  The  static  machine,  which 
generates  electricity  by  friction,  develops  a  very  high  electro- 
motive force,  and  consequently  the  electricity  is  of  high 
potential.  When  the  patient  is  insulated  from  the  ground 
and  connected  with  one  of  the  conductors  he  becomes  en- 
veloped in  a  layer  of  electricity  which  is  confined  by  the  dry 
air.  When  the  other  electrode  is  approached  the  current  flies 
to  the  zero  point,  just  as  a  large  volume  of  water,  which  had 
been  dammed,  would  do  when  the  dam  bursts.  It  does  so 
with  such  force  that  it  leaps  through  space,  and  by  igniting 
the  small  particles  from  the  conductors  causes  a  sparh. 

The  galvanic  or  constant  current  is  commonly  produced  by 
chemical  action  upon  two  dissimilar  substances.  The  current 
flows  from  the  substance  most  acted  upon  (the  positive  ele- 
ment) to  that  least  so  (the  negative  element) ;  and  if  they  are 
connected  by  a  conductor,  from  this  back  again  to  the  posi- 
tive.    Such  a  combination  of  substances  is  termed  a  cell  (see 


68 


ELECTRICITY. 


Fig.  15).  A  combination  of  cells  constitutes  a  battery.  The 
point  from  which  the  current  leaves  the  cell  (the  negative 
element)  is  called  the  positive  pole ;  and  that  where  it  enters, 
the  positive  element,  or  the  negative  pole.  This  constitutes  a 
circuit.     So  long  as  the  circuit  is  closed  a  constant  E.  M.  F. 

Fig.  15. 


Zn  Cu 

This  represents  a  vessel  filled  with  dilute  H2SO4,  into  which  plates  of  zinc  and  cop- 

Eer  are  immersed  and  connected  by  a  piece  of  wire.    The  current  starts  at  Zn, 
ows  to  Cu,  and  hence  through  the  wire  to  Zn  again.    Cu  is  the  positive  pole,  or 
anode ;  Zn  the  negative  pole,  or  cathode. 

is  maintained  and  the  current  will  flow ;  when  the  circuit  is 
open,  the  current  ceases. 

The  faradic  current  is  produced  by  induction — i.  e.,  if  we 
make  a  coil  out  of  the  wire  which  connects  the  two  elements  of 
a  cell,  and  surround  this  coil  with  another  one  having  no  connec- 
tion with  it,  and  open  and  close  the  circuit  in  the  first  or  pri- 
mary coil,  an  E.  M.  F.  will  be  generated,  which  will  cause  a  cur- 
rent to  flow  in  the  second  or  secondary  coil.  This  current  is  but 
momentary,  only  occurring  \^dlen  the  circuit  is  closed  and 
opened.  A  current  constantly  flowing  through  the  primary 
coil  would  not  induce  a  current  in  the  secondary  coil.  The 
induced  current  is  an  alternating  or  to-and-fro  current.  When 
the  circuit  is  closed  or  made,  the  induced  current  in  the  sec- 
ondary coil  flows  in  the  opposite  direction,  while  the  current 
induced  by  l)reaking  tJie  circuit  flows  in  the  same  direction  as 
that  of  the  inducing  current.  When  a  bar  of  soft  iron  in  the 
centre  of  the  primary  coil  is  suddenly  magnetized  by  closing 
the  circuit  and  demagnetized  by  breaking  it,  currents  are  in- 
duced in  the  secondary  coil.     The  current  induced  by  mag- 


PHYSIOLOGY.  59 

netization  flows  in  the  same  direction  as  that  produced  by  clos- 
ing the  circuit;  and  that  induced  by  demagnetization,  as  that 
produced  when  the  circuit  was  broken.  Under  such  cir(!um- 
stances  there  would  be  a  double  influence  acting  upon  the 
secondary  coil,  with  consequent  increased  strength  of  current. 
This  principle  is  made  use  of  in  the  construction  of  medical 
batteries  for  increasing  current-strength. 

As  any  variation  in  the  strength  of  the  current  in  a  circuit 
will  induce  a  current  in  the  conductor,  a  current  is  induced 
in  the  coils  of  the  primary  coil.  This  is  termed  the  extra 
current.  In  batteries  this  is  designated  as  the  primary  cur- 
rent. It  obeys  the  same  laws  as  to  direction  that  the  current 
induced  in  the  secondary  coil  does.  Accordingly  when  the 
circuit  is  closed,  the  induced  current  goes  in  the  opposite 
direction  and  they  tend  to  neutralize  each  other.  This  cur- 
rent may  be  consequently  disregarded  and  the  extra  current 
considered  as  flowing  in  only  one  direction. 

The  strength  of  the  faradic  current  increases  with  the 
strength  of  the  generating  current,  the  number  of  windings 
in  the  coil,  the  approximation  of  the  coils,  and  the  sudden- 
ness of  the  change  of  current-strength.  When  the  primary 
coil  is  surrounded  by  the  secondary,  the  inducing  current  is 
weakened  by  its  induction  of  a  current  in  the  secondary  coil. 
Hence  the  extra  current  induced  would  be  weakened.  Hence 
the  extra  current  grows  stronger  as  the  secondary  coil  is  re- 
moved from  the  primary.  This  is  utilized  in  the  construc- 
tion of  the  Duhois-Reymond  coil,  the  extra  current  being 
strongest  when  the  secondary  coil  is  slid  away  from  the  pri- 
mary. 

Physiology. 

The  electrical  current  acts  upon  living  tissues  in  various  ways. 

It  may  cause  electrolysis  or  chemical  decomposition  of  the 
tissues  at  the  electrodes,  a  property  taken  advantage  of  for 
the  destruction  of  nsevi,  small  tumors,  etc. 

It  possesses  the  power  of  cataphoresis — i.  e.,  of  carrying 
solutions  through  the  tissues  in  the  direction  of  the  current. 
By  means  of  this  property  cocaine  for  local  anaesthesia  and 
other  drugs  may  be  introduced  into  the  body  at  the  seat  of 
disease. 


60  ELECTRICITY. 

It  causes  a  modification  of  nerve-excitability  known  as 
electrotonus.  At  and  in  the  vicinity  of  the  anode  the  excita- 
bility is  lessened,  anelectrotonus  ;  while  at  and  in  the  vicinity 
of  the  cathode  the  excitability  is  increased,  catelectrofonus. 
Also  when  anelectrotonus  is  made  to  disappear  suddenly  by 
breaking  the  circuit  at  the  anode,  the  cathodal  increase  occurs, 
and  the  nerve  is  thrown  into  a  condition  of  ccdelectrotonus. 

The  current  also  causes  muscular  contraction.  These  con- 
ditions can  only  be  produced  by  a  sudden  increase  or  decrease 
of  electrical  excitement  in  the  muscle  or  nerve  supplying  it. 
In  other  words,  by  a  sudden  increase  or  decrease  of  current- 
strength.  When  this  is  done  gradually  no  contraction  results. 
This  being  true,  the  most  powerful  excitement  is  caused  by 
the  voltaic  alternative.  It  is  produced  by  suddenly  reversing 
the  current  direction,  so  that  a  nerve  or  muscle  which  had 
been  in  a  condition  of  anelectrotonus  is  thrown  into  one  of 
catelectrotonus,  or  from  a  state  of —  excitability  to  one  of  -\-, 
and  ince  versa.  By  simple  closure  and  opening  of  the  circuit 
the  increase  is  only  from  0  to  -f-  excitability  and  0  to  —  ex- 
citability, which,  of  course,  is  not  so  great  a  variation. 

The  galvanic  current  possesses  all  of  these  properties  in 
more  marked  degree  than  does  the  static  or  far  adic.  In  these 
latter  the  influence  of  the  current  is  of  such  brief  duration 
that  they  are  practically  only  used  to  cause  muscular  con- 
tractions and  to  relieve  pain. 

A  degenerating  muscle  loses  its  power  of  response  to  static 
electricity  first ;  next,  to  faradic,  and  then  to  simple  opening 
and  closing  of  the  galvanic  circuit ;  finally,  to  the  voltaic 
alternative. 


Diagnosis  and  Prognosis. 

Electric  irritability  :  In  many  diseases  of  the  nervous  sys- 
tem the  muscles  and  nerves,  when  subjected  to  electrical 
stimulation,  act  differently  than  do  normal  muscles  and  nerves. 
Their  electric  irritahility  may  differ  in  two  ways — either  in 
quantity,  meaning  a  diminution  or  increase  of  irritability  ; 
or  in  quality,  in  which,  along  with  the  quantitative  change, 
there  is  one  in  the  character  of  the  contraction. 

Quantitative  changes :  Simple  increased  irritability,  or  that 


DIAGNOSIS  AND  PROGNOSIS.  61 

in  which  the  muscle  or  nerve  responds  to  a  weaker  current 
than  normal,  is  met  with  most  frequently  in  tetany. 

Decreased  irritability,  or  that  in  which  a  stronger  current 
than  normal  is  required  to  produce  contractions,  occurs  in 
mild  cases  of  neuritis  and  sometimes  in  long-standing  central 
paralyses.  These  conditions  are  generally  the  same  for  botli 
currents.  ^ 

Quantitative  changes — examination :  To  ascertain  these 
facts  :  if  the  paralysis  exists  on  one  side  only,  the  weakest 
current  that  will  cause  contraction  of  the  normal  muscle 
should  first  be  learued  ;  then  the  difference  in  the  strength 
of  current  necessary  to  produce  the  same  result  on  the  dis- 
eased muscles. 

If  the  affection  is  bilateral,  the  reactions  may  be  similarly 
compared  with  the  reactions  of  another  normal  person  ;  or 
we  judge  by  experience  as  to  what  strength  of  current  is  usu- 
ally normally  required. 

The  qualitative  changes  consist  of  the  reaction  of  degenera- 
tion (De  R)  and  the  viyotonic  muscular  reaction.  The  former 
is  found  in  certain  forms  of  paralysis,  and  when  present 
always  indicates  that  the  causal  lesion  is  situated  in  the  periph- 
eral motor  neuron — i.  e.,  either  in  the  motor  cells  of  the 
medulla  or  cord,  or  the  axons  forming  the  motor  nerves  which 
come  from  them.  The  latter  is  a  symptom  of  myotonia  con- 
genita. 

Reactions  of  degeneration  are  complete  or  partial  according 
to  the  degree  of  disturbance. 

The  complete  reaction  consists  of:  (1)  a  rapid  loss  of  the 
power  of  the  muscle  and  its  supplying  nerve  to  react  to  the 
faradic  current ;  (2)  a  brief  period  of  quantitative  increase  fol- 
lowed by  a  decrease  when  they  are  stimulated  by  the  galvanic 
current;  (3)  the  modal  change — i.  e.,  instead  of  tlie  short, 
quick,  jerky  contraction  caused  by  the  stimulation  of  the 
healthy  muscle  or  nerve  by  a  galvanic  current,  the  contrac- 
tion is  slow,  wavy,  and  sometimes  tetanic ;  and  (4)  the  serial 
change,  when  the  muscle  alone  is  subjected  togalvauic  stimu- 
lation. 

The  serial  change  dej)ends  upon  a  difference  in  the  way  the 
muscle  reacts  to  the  different  poles  of  the  battery.  Normally 
the  weakest  current  that  will  cause  a  muscular  contraction  is 


62  ELECTRICITY. 

when  the  circuit  is  dosed  with  the  cathode  on  the  muscle 
(cathodal  closing  contraction,  CaClC).  A  little  stronger  cur- 
rent will  cause  an  anodal  closing  contraction  (AnClC);  and  so 
on.  Representing  anodal  opening  contraction  by  AnOC  and 
cathodal  opening  contraction  by  CaOC,  the  normal  formula 
will  be  CaClC  >  AnClC  >  AnOC  >  CaOC. 

The  serial  change  in  a  complete  De  R  consists  of  an  increase 
of  the  AnClC  and  AnOC  over  the  CaClC ;  so  that  one  for- 
mula would  read  AnClC  =  AnOC  >  CaClC  >  CaOC.  Or 
this,  AnClC  >  AnOC  >  CaClC  >  CaOC. 

The  partial  De  R  is  more  common  than  the  complete. 
It  may  consist  of  nothing  but  the  loss  of  faradic  irritabil- 
ity and  the  modal  change,  the  series  being  normal.  Or  this 
may  be  changed  so  that  AnClC  =  CaClC.  In  partial  reac- 
tions the  nerve  usually  responds  normally. 

In  examining  for  the  presence  of  De  R  we  first  use  the 
faradic  current  as  when  testing  for  quantitative  changes. 
Then  use  the  galvanic  electrode,  placing  a  large  indifferent 
electrode  over  the  sternum,  and  the  other,  a  small  one,  over 
the  muscle.  We  then  find  the  minimum  strengths  of  current 
necessary  to  cause  CaClC  and  AnClC.  If  a  meter  is  at 
hand,  this  may  be  done  by  noting  the  number  of  milliamperes 
required ;  or  if  not,  by  noting  that  the  current  which  causes 
CaClC  will  not  cause  AnClC,  or  vice  versa;  or  that  they  are 
equal. 

Another  method  consists  in  making  the  electrode  positive 
and  negative  alternately,  using  the  same  strength  of  current 
and  noting  the  difference,  if  any,  in  the  intensity  of  the  con- 
tractions. In  all  of  these  tests  there  should  be  a  considerable 
interval  (several  seconds)  between  opening  and  closing  the 
circuit. 

The  myotonic  reaction  is  due  to  a  greatly  increased  irrita- 
bility :  mild  faradic  and  galvanic  currents  produce  contractions 
that  are  tetanic  in  character,  hollows  and  ridges  in  the 
muscle  being  often  produced.  In  the  case  of  the  galvanic 
current  AnClC  becomes  equal  to  or  greater  than  CaClC. 
AVhen  the  galvanic  current  is  allowed  to  flow  without  inter- 
ruption through  a  muscle,  rhythmical  contractions,  ti'avelling 
from  the  negative  to  the  positive  pole  occur. 

Electricity  may  sometimes  help  us  in  forming  a  prognosis. 


METHODS  OF  APPLICATION  AND  THERAPEUTICS.    63 

As  the  complete  De  R  is  only  present  when  extensive  damage 
has  been  done,  the  prognosis  should  be  more  grave  than  when 
only  the  partial  De  R  is  present.  It  is  best  in  those  oases 
where  no  serial  change  occurs.  Cases  in  which  only  a  feeble 
AnClC  can  be  elicited  may  be  regarded  as  hopeless. 

Methods  of  Application  and  Therapeutics. 

Certain  general  rules  should  be  borne  in  mind  while  using 
electricity.  The  muscles  being  treated  or  tested  should  be 
relaxed  and  in  a  comfortable  position.  To  cause  muscular 
contraction  we  should  begin  with  a  weak  current,  gradually 
increasing  its  strength  until  a  slight  contraction  is  produced. 
Violent  contractions  are  harmful.  Ten  to  twelve  contractions 
of  each  muscle  are  sufficient.  When  using  strong  galvanic 
currents  always  increase  and  decrease  their  strength  grad- 
ually ;  otherwise  a  painful  shock  will  be  caused.  To  influ- 
ence a  particular  spot  use  a  large  indiiferent  electrode,  and  a 
small  one  over  the  spot.  To  influence  a  considerable  area 
two  large  electrodes  may  be  used.  To  influence  the  skin  the 
electrodes  should  be  dry  ;  to  reach  the  tissues  under  the  skin, 
both  electrodes  should  be  moist  with  water  or  a  saline  solu- 
tion. The  motor  point  is  a  certain  spot  in  each  mnscle  that 
is  more  irritable  to  the  action  of  the  current  (see  Figs.  16  to 
25).  When  there  is  great  quantitative  decrease  contractions 
too  faint  to  be  seen  may  be  often  recognized  by  placing  the 
finger  lightly  on  the  muscle. 

In  the  treatment  of  nervous  diseases  electricity  is  used  as  a 
tonic,  either  to  the  general  system  or  to  individual  muscles 
and  nerves  ;  to  increase  the  sensibility  of  the  skin  ;  as  a  seda- 
tive, for  the  relief  of  pain  and  spasm ;  and  for  the  introduc- 
tion of  drugs  into  the  diseased  parts  by  utilizing  the  property 
of  cataj^horesis.  As  a  tonic,  we  may  employ  static,  faradic, 
or  galvanic  electricity.  > 

Static  electricity  used  as  a  tonic :  We  place  the  patient 
upon  an  insulated  stool,  connect  him  with  one  of  the  poles 
of  the  machine,  and  by  means  of  a  metal  ball-electrode 
attached  to  the  other  pole  we  draw  sparks  from  various  parts 
of  the  body,  excepting  the  face,  if  used  for  a  general  etfect; 
or  from  the  paralyzed  or  anaesthetic  part,  if  the  aifection  is 


64 


ELECTRICITY. 


local.     This  may  be  done  without  removing  the  clothing. 
As  a  muscle-stimulant  its  employment  is  only  of  benefit  in 


A  diagram  of  the  motor  points  of  the  face,  showing  the  position  of  tlie  electrodes 
during  electrization  of  special  muscles  and  nerves.  The  anode  is  supposed  to 
be  placed  in  the  mastoid  fossa,  and  the  cathode  in  the  part  indicated  upon  the 
diagram  (from  von  Ziemssen).  1,  oceipitofrontalis  (ant.  belly) :  2,  corrugator 
supercilii ;  3,  occiplto-frontalis  (post,  belly) ;  4,  orbicularis  palpebrarum  ;  5,  re- 
trahens  et  attollens  aurxim  ;  6,  pyraniidalis  nasi ;  7,  facial  nerve  ;  8,  lev.  lab.  sup. 
et  alse  nasi ;  9,  deep  posterior  auricular  branch  of  facial  nerve  :  10,  lev.  lab.  sup. 
propr. ;  11,  stylo-hyoid  ;  12,  dilator  naris  ant. ;  13,  digastric  ;  14,  dilator  naris  post.  ; 
15,  buccal  branches  of  facial  nerve;  16,  zygomat.  niinor :  17,  subcutaneous 
branch  of  inferior  maxillary  nerve ;  18,  zygomat.  major ;  19,  splenius  capitis  ; 
20,  orbicularis  oris  ;  21,  external  branch  of  spinal  accessory  nerve  ;  22,  branch 
of  levator  menti  and  dep.  ang.  oris  ;  23,  sterno-mastoid  ;  24,  levator  menti ;  25, 
sterno-mastoid ;  26,  dep.  lab.  infer. ;  27,  levator  anguli  scapulre  :  28,  dep.  ang, 
oris;  29,  phrenic  nerve;  30,  subcutaneous  nerves  of  neck;  31,  posterior  thoracic 
nerve  to  rhomboid  muscles ;  32,  sterno-hyoid ;  33,  circumflex  nerve ;  34,  omo- 
hyoid;  35,  posterior  thoracic  nerve  to  serratus  magnus;  36,  sterno-thyroid  ; 
37,  branch  of  brachial  plexus  ;  38,  branch  for  platysma ;  40,  steruo-hyoid ;  42, 
omo-hyoid ;  44,  46,  nerves  to  pectoral  muscles. 

central  paralyses.     The  psychic  ejects  of  static  electricity  are 
marked ;  hence  it  is  of  value  in  the  treatment  of  hysterical 


METHODS  OF  APPLICATION  AND   THERAPEUTICS.    65 

affections.       The    applications    should    last    from    fifteen    to 
twenty  minutes,  made  tri-weekly. 

The  faradic  current,  as  a  musole-stimulant,  is  only  of  use  in 
central  paralyses,  or  in  peripheral,  when  the  muscle  is  hut 
slightly  degenerated.  Either  the  so-called  primary  or  the 
secondary  current  may  be  used,  the  latter  being  somewhat 
the  more  powerful. 

Fig.  17. 


Trans,  ab- 
dominis. 


Diagram  of  the  motor  points  of  the  trunk  (from  von  Ziemssen). 

A  convenient  method  when  using  the  slowly  interrupted 
current  is  to  place  a  good-sized  electrode  over  the  nerve  sup- 
plying the  muscle,  say,  over  the  brachial  ])lexus  if  the  arm  is 
being  treated,  while  the  other  electrode,  which  should  be  of 
smaller  size,  is  placed  over  the  motor  ])oints  (points  in  the 
muscles  more  irritable  to  the  current:  Figs.  16,  17,  18,  19, 
20,  21,  22,  23,  24,  25)  of  tiie  muscles  l)eiug  treated.     Or,  if 


66 


ELECTRICITY. 


the  rapidly  interrupted  current  only  is  convenient,  the  indif- 
ferent electrode  being  in  the  position  above  described,  we 
stroke  the  paralyzed  part  with  the  other.  This  method  does 
not  necessitate  a  knowledge  of  the  position  of  the  motor 


Fig.  18. 


Diagram  of  the  motor  points  of  the  arm,  under  side  (from  von  Ziemssen).  1,  Mus- 
culo-cutaneons  nerve  ;  2,  musculo-cutaneous  nerve ;  3,  biceps ;  4,  internal  nerve 
of  triceps ;  6,  median  nerve ;  8,  brachialis  anticus ;  10,  ulnar  nerve ;  12,  branch 
of  median  nerve  to  the  pronator  teres. 


Motor  parts  of  the  arm,  outer  side  (from  von  Ziemssen).  1,  external  head  of  tri- 
ceps ;  2,  musculo-spiral  nerve ;  3,  brachialis  anticus  ;  4,  supinator  longus ;  5,  ex- 
tensor carpi  radialis  longior ;  6,  extensor  carpi  radialis  brevier. 


points.     An   application   every   other  day   is   usually  often 
enough. 

When  used  to  stimulate  ancesthetic  shin  we  employ  the  wire 
brush  and  the  secondary  current  rapidly  interrupted.     The 


METHODS  OF  APPLICATION  AND   THERAPEUTICS.    67 
Fig.  20. 


Motor  points  of  forearm,  inner  surface  (from  von  Ziemssen).  1,  flexor  carpi 
radialis ;  2,  branch  of  the  median  nerve  for  tlie  pronator  teres ;  3,  flexor  pro- 
fundus digitorum;  4,  palmaris  longus ;  5,  flexor  sublimis  digitorum  :  6,  flexor 
carpi  ulnaris;  7,  flexor  longus  pollieis  :  8,  flexor  sublimis  digitorum  (middle 
and  ring  fingers);  9,  median  nerve;  10.  ulnai-  nerve;  11,  abductor  pollieis;  12, 
flexor  sublimis  digitorum  (index  and  little  fingers);  i:''.,  uiiponens  pollieis;  14, 
deep  branch  of  ulnar  nerve;  15,  flexor  brevis  pollieis;  ic,  |.:iliiiaris  brevis  ;  17, 
adductor  jiollicis  ;  18,  adductor  minimi  digit! :  19,  lumbricalis  (first);  20,  flexor 
brevis  minimi  digiti  :  22,  (ipj)onens  minimi  digiti ;  24,  liniil)ricales  (second,  third, 
and  fourtli). 


68 


ELECTRICITY. 


brush  is  placed  over  the  anaesthetic  areas,  the  other  being  at 
some  indifferent  point.     This  should  be  done  daily,  at  least. 


Fig.  21. 


Motor  points  of  forearm,  outer  surface  (from  von  Ziemssen).  1,  extensor  carpi 
ulnaris  ;  2,  supinator  longus  ;  ?.,  extensor  minimi  digiti ;  4,  extensor  carpi  radialis 
longioi- ;  5,  extensor  indicis;  6,  extensor  carpi  radialis  brevior;  7,  extensor 
secundi  internodii  pollicis;  8,  extensor  communis  digitorum ;  9,  abductor 
minimi  digiti  :  10,  extensor  indicis  ;  11,  dorsal  interosseus  (fourth) ;  12,  exten- 
sor indicis  and  extensor  ossis  metacarpi  pollicis;  14,  extensor  ossis  metacarpi 
pollicis;  16,  extensor  primi  internodii  pollicis;  18,  flexor  longus  pollicis;  20, 
dorsal  interossei. 

For  gciifral  ionic  y>/fryjr).sr.s'  we  employ  the  method  known 
as  general  faradization.     The  patient  is  placed  in  a  recum- 


METHODS  OF  APPLICATION  AND   THERAPEUTICS    69 

bent  position  and  all  the  muscles  of  the  hody  caused  to  con- 
tract in  turn  by  one  of  the  methods  aliove  described.     After 


Fig.  2-1 


FKi.  -I'i. 


Motor  points  of  thigh,  anterior  surface.  Posterior  surface. 

(From  von  Ziemssen.) 

Fig.  22.— 1,  tensor  vaginae  femoris  (branch  of  superior  gluteal  nerve);  2,  anterior 
crural  nerve  ;  3,  tensor  vagiiiBB  femoris  (branch  of  crural  nerve) ;  4,  obturator 
nerve  ;  5,  rectus  femoris  :  6,  sartorius  ;  7,  vastus  externus  ;  8,  adductor  longus  ; 
9,  vastus  externus  ;  10,  branch  of  crural  nerve  to  quadriceps  extensor  cruris  ; 
12,  crureus ;  14,  branch  of  crural  nerve  to  vastus  externus. 

Fig.  23.— 1,  adductor  magnus  ;  2,  inferior  gluteal  nerve  for  gluteus  maximus ;  3,  semi- 
tendinosus:  4,  great  sciatic  nerve;  5,  semi-membranosus :  6,  long  head  of 
biceps  ;  7,  gastrocnemius  (internal  head) ;  8,  short  head  of  biceps;  10,  posterior 
tibial  nerve  ;  12,  peroneal  nerve  ;  14,  gastrocnemius  (external  head)  ;  16,  soleus. 


this  is  done  one  pole  may  be  placed  at  the  nape  of  the  neck, 
the  other  at  the  feet,  and  the  current  rapidly  interrupted  and 
made  strong  enough  to  produce  a  general  tingling  through 


70 


ELECTRICITY. 


Fig.  24. 


Fig.  25. 


Motor  points  of  the  leg,  outer  side.  Inner  side. 

(Prom  von  Ziemssen.) 
Fig.  24.— 1,  peroneal  nerve  ;  2,  peroneus  longus  ;  3,  gastrocnemius  (external  head) ; 
4,  tibialis  antieus  ;  5,  soleus  ;  6,  extensor  longus  poUicis  ;  7,  extensor  communis 
digitorum  longus  ;  8,  branch  of  peroneal  nerve  for  extensor  brevis  digitorum  ; 
9,  peroneal  brevis;  10,  dorsal  interossei ;  11,  soleus  :  13,  flexor  longus  poUicis; 
15,  extensor  brevis  digitorum  ;  17,  abductor  minimi  digiti. 
Fig.  25.— 1,  gastrocnemius  (internal  head) ;  2,  soleus  ;  3,  flexor  communis  digitorum 
longus  ;  4,  posterior  tibial  nerve  :  5,  abductor  pollicis. 

the  body  for  fifteen  or  twenty  minutes.  The  treatment 
should  be  administered  daily,  except  in  women  while  men- 
struating. 


METHODS  OF  APPLICATION  AND   THERAPEUTICS.    71 

The  faradic  current,  especially  wlicn  rapidly  interrupted, 
exercises  considerable  psychic  influence. 

The  galvanic  current  when  used  to  influence  the  nvirilion 
of  muscles  much  degenerated,  as  in  severe  acute  poliomyelitis, 
is  best  used  by  placing  the  anode  at  some  indifferent  point 
(best  over  the  supplying  nerve),  Avhile  the  cathode  is  rubbed 
over  the  muscles  without  breaking  the  circuit  {labile)',  or  by 
allowing  the  cathode  to  remain  stationary  at  the  distal  ex- 
tremity of  the  limb  and  the  current  allowed  to  flow  from  ten 
to  fifteen  minutes  (stabile).  If  we  wish  to  cause  'muscular 
contractions,  the  cathode  is  placed  over  the  motor  points  and 
the  circuit  opened  and  closed  alternately,  at  the  cathode.  Or 
the  voltaic  alternative  reversion  of  the  current  may  be  used. 
Seances  when  the  current  is  employed  labile  or  stabile  may 
be  daily.  When  contractions  are  caused,  tri-weekly  is 
sufficient. 

In  high  grades  of  peripheral  paralyses  the  galvanic  current 
is  the  only  one  of  value. 

As  a  general  tonic  it  may  be  used  as  general  galvanization, 
applied  similarly  to  general  faradization. 

Sedative  influences  are  exercised  by  each  of  the  three  forms 
of  current. 

We  may  secure  the  sedative  influence  of  the  static  current  by 
drawing  sparks  from  the  painful  region,  as  described  on  p.  63. 
There  are  other  methods,  for  which  the  reader  is  referred  to 
works  on  electro-therapeutics.  The  faradic  cfiirrent,  most 
markedly  that  from  the  secondary  current,  rapidly  inter- 
rupted, exercises  a  sedative  influence.  We  employ  it  by 
placing  an  electrode  over  the  painful  area.  The  seance 
should  last  five  to  ten  minutes  and  be  repeated  frequently. 
Local  spasms  may  sometimes  be  relaxed  by  the  same  method. 

In  using  the  galvanic  current  to  relieve  pain  or  spasm  the 
anode  is  placed  over  the  part  to  be  influenced  while  the 
cathode  is  removed  as  far  away  as  possible.  The  current  is 
applied  stabile  or  labile,  being  gradually  increased  and  very 
gradually  decreased  in  strength.  The  current  should  be  as 
strong  as  can  be  borne,  and  used  frequently. 

Cataphoresis  is  used  in  neurology  principally  in  the  treat- 
ment of  neuralgia.     If  a  solution  of  cocaine  10  per  cent,  is 


72  MASSAGE. 

used  to  moisten  the  anode  which  is  placed  over  the  painful 
nerve,  some  of  the  cocaine  will  pen{>trate  the  skin  and  directly 
affect  the  painfid  part.  Special  electrodes,  the  best  of  which 
is  Peterson's,  have  been  devised  for  the  employment  of 
cataphoresis. 

MASSAGE. 

Massage  is  the  name  given  to  a  number  of  manipulations 
of  the  body,  which  possess  marked  value  in  the  treatment  of 
nervous  diseases  as  Avell  as  of  others. 

Effects :  Massage  properly  applied  stimulates  the  flow  of 
the  lymph-  and  venous  currents  ;  increases  temporarily  the 
number  of  red  blood-corpuscles  ;  accelerates  the  heart's  action  ; 
stimulates  the  motor  nerve-endings  and  muscular  contrac- 
tility ;  and,  according  to  the  method  used,  exercises  either  a 
stimulant  or  a  sedative  action  upon  the  sensory  nerves. 

Indications :  It  is  therefore  of  value  in  various  forms  of 
neurasthenia;  hysteria;  motor  paralysis;  ansesthesia ;  head- 
ache ;  neuralgia  ;  function -spasms  ;  insomnia  ;  and  constipa- 
tion. It  should  not  be  employed  where  there  is  a  diseased 
heart  or  bloodvessels. 

To  administer  massage  properly  requires  special  training. 
The  movements  consist  of  effiewrage,  or  gentle  stroking  ;  mas- 
sage dfrietion,  consisting  of  vigorous  strokes  with  one  hand 
and  strong  circidar  and  to-and-fro  friction  with  the  other ; 
p^h'issage,  or  kneading  ;  and  tapotement,  or  striking  with  the 
hands  or  ends  of  the  fingers.  Passive  movements  are  fre- 
quently combined  with  these.  Efileurage  and  tapotement 
are  most  useful  in  treating  painful  conditions. 

Muscular  Movements. 

Regular  muscular  movements,  according  to  a  fixed  schedule, 
as  first  used  by  Weir  Mitchell,  but  since  elaborated  by 
Frankel,  are  of  value  in  the  treatment  of  muscular  inco- 
ordination. The  exercises  should  be  performed  with  care 
and  precision  twice  daily. 

The  following  schedule,  based  upon  that  of  Frankel  and 
Hirschberg,  is  recommended  by  Dana  : 

Exercises  for  the  hands  and  arms  :   1.  Sit  in  front  of  a  table  ; 


MUSCULAR  MOVEMENTS.  73 

place  the  hand  upon  it,  then  (elevate  each  finger  as  far  as  pos- 
sible. Then,  raising  the  hand  slightly,  extend  and  then  flex 
each  finger  and  thumb  as  far  as  possil)Ie.  1)0  this  first  with 
the  right,  then  with  the  left.     Repeat  oikh'. 

2.  With  the  hand  extended  on  the  table,  abduct  the  thumb 
and  then  each  finger  separately,  as  far  as  possible.  Repeat 
three  times. 

3.  Touch  with  the  end  of  tlie  thumb  each  finger-tip  sepa- 
rately and  exactly.  Then  touch  the  middle  of  each  phalanx 
of  each  of  the  four  fingers  with  the  tip  of  the  thumb.  Re- 
peat three  times. 

4.  Place  the  hand  in  the  position  of  piano-playing  and  ele- 
vate the  thumb  and  fingers  in  succession,  bringing  them  down 
again,  as  in  striking  the  keys  of  the  piano.  Do  this  twenty 
times  with  the  right  hand,  and  the  same  with  the  left. 

5.  Sit  at  a  table  with  a  large  sheet  of  paper  and  pencil. 
Make  four  dots  in  the  four  corners  of  the  paper  and  one  in 
the  centre.  Draw  lines  from  corner  dots  to  centre  dot  with 
right  hand  ;  same  with  the  left. 

6.  Draw  another  set  of  lines  parallel  to  the  first,  with  the 
right  hand  ;  same  with  the  left, 

7.  Throw  ten  pennies  upon  the  paper.  Pick  them  up  and 
place  them  in  a  single  pile  with  the  right  hand  ;  then  with  the 
left.     Repeat  twice. 

8.  Spread  the  pennies  about  on  the  table.  Touch  each  one 
slowly  and  exactly  with  the  forefinger  of  the  right  hand  ;  then 
with  the  forefinger  of  the  left. 

9.  Place  an  ordinary  solitaire  board  on  the  table,  with  the 
marbles  in  the  groove  around  the  holes.  Put  the  marbles  in 
their  places  with  the  right  hand  ;  same  with  the  left  hand. 
Patient  may,  with  advantage,  practise  the  game  for  the  pur- 
pose of  steadying  his  hands. 

10.  Take  an  ordinary  fox-and-geese  board  with  holes  and 
pegs,  and,  beginning  at  one  corner,  place  the  pegs  in  the 
holes,  one  after  the  other,  using  first  the  right  hand,  and  then 
the  left. 

Exercises  for  the  body  and  lower  limbs :  1 .  Sit  in  a  chair. 
Rise  slowly  to  the  erect  position  without  help  from  cane  or 
arms  of  chair.  Sit  down  slowly  in  the  same  way.  Repeat 
once. 


74  HYDROTHERAPEUTICS. 

2.  Stand  with  cane,  feet  together,  advance  the  left  foot  and 
return  it.     Same  with  the  right.     Repeat  three  times. 

3.  Walk  ten  steps  with  cane,  slowly.  Walk  backward  five 
steps  with  cane,  slowly. 

4.  Stand  without  cane,  feet  a  little  spread  out,  hands  on  hips. 
In  this  position  flex  the  knees,  and  stoop  slowly  down  as  far 
as  possible  ;  rise  slowly  ;  repeat  twice. 

5.  Stand  erect,  carry  left  foot  behind,  and  bring  it  back  to 
its  place  ;  the  same  with  the  right.     Repeat  three  times. 

6.  Walk  twenty  steps,  as  in  exercise  No.  3 ;  then  walk 
backward  five  steps. 

7.  Repeat  No.  2  without  cane. 

8.  Stand  without  cane,  heels  together,  hands  on  hips.  Stand 
in  this  way  until  you  can  count  twenty.  Increase  the  dura- 
tion each  day  by  five,  until  you  can  stand  in  this  way  while 
one  hundred  is  being  counted. 

9.  Stand  without  cane,  feet  spread  apart ;  raise  the  arms 
up  from  the  sides  until  they  meet  above  the  head.  Repeat 
this  three  times.  With  the  arms  raised  above  the  head,  carry 
them  forward  and  downward,  bending  with  the  body  until 
the  tips  of  the  fingers  come  as  near  the  floor  as  they  can  be 
safely  carried, 

10.  Stand  without  cane,  feet  spread  apart,  hands  on  hips  ; 
flex  the  trunk  forward,  then  to  the  left,  then  backward,  then  to 
the  right,  making  a  circle  with  the  head.     Repeat  three  times. 

11.  Do  No.  9  with  heels  together. 

12.  Do  No.  10  with  heels  together. 

13.  Walk  along  a  fixed  line,  such  as  a  seam  on  the  carpet, 
with  cane,  placing  the  feet  carefully  on  the  line  each  time. 
Walk  a  distance  of  at  least  fifteen  feet.     Repeat  twice. 

14.  Do  the  same  without  cane. 

15.  Stand  erect  with  cane;  describe  a  circle  on  the  floor 
with  the  toe  of  the  right  foot.  Same  with  the  left.  Repeat 
twice.  Between  the  fifth  and  sixth  exercise  the  patient 
should  rest  for  a  few  moments. 


HYDROTHERAPEUTICS. 

Water  may  be  used  either  as  a  tonic  or  as  a  sedative. 

As  a  tonic  we  employ  cold  plunges ;  shower-baths ;  various 


HYDROTHERAPEUTICS.  75 

forms  of  douches,  as  Charcot's  and  tlie  Scottish  cold  sitz-bath  ; 
salt  baths,  either  sea  or  artificial,  and  short  cold  packs.  These 
all  have  a  stimulating  and  tonic  effect.  In  giving  them,  es- 
])ecially  to  weak  people,  it  is  best  to  begin  with  warm  water 
and  gradually  lower  the  temperature.  Showers  and  douches 
are  the  most  stimulating.  A  reaction  should  always  be 
obtained  by  vigorous  rubbing  afterward. 

For  the  cold  plunge  the  patient  jumps  into  a  tub  of  water 
at  a  temperature  of  60°  to  70°  F.,  and  at  once  jumps  out. 
He  should  then  be  rubbed  vigorously. 

The  shower-  or  rain-bath  consists  in  allowing  water  to  fall 
on  the  body  from  a  height  for  one  or  two  minutes,  Avhile  the 
feet  are  in  warm  water.  Frictions  of  the  body  should  be 
kept  up  during  this  process. 

A  Charcot  douche  is  given  by  directing  a  solid  stream  of 
water  with  force  upon  the  back  of  the  patient. 

By  the  Scottish  douche  we  mean  alternating  a  cold  douche 
with  a  warm  or  a  hot  one. 

Cold  packs  are  given  by  wringing  a  sheet  out  in  cold  water, 
wrapping  it  about  the  patient  for  a  few  moments ;  when  it  is 
removed  and  the  patient  put  to  bed  and  rubbed. 

An  artificial  salt  bath  may  be  made  by  putting  twenty-five 
pounds  of  salt  in  thirty  gallons  of  water  (2  per  cent.).  It 
may  be  warm  or  cold. 

To  obtain  sedative  effects  we  may  use  the  lukewarm  bath, 
wet  pack,  hot  sitz-baths,  hot  compresses,  and  drip  sheet. 

The  lukewarm  bath  is  given  at  a  temperature  of  95°  to  98° 
F.  for  ten  to  twenty  minutes. 

To  give  a  wet  pack  we  spread  a  large,  thick  blanket  upon 
the  bed ;  upon  this  is  laid  a  sheet  wrung  out  in  water  at  a 
temperature  of  40°  to  60°  F.  The  nude  patient  lies  upon 
this  and  the  sheet  is  wrapped  smoothly  about  him,  not  in- 
cluding the  head  and  feet.  The  sheet  must  be  carried  be- 
tween the  legs  and  brought  evenly  in  contact  with  the  body. 
The  blanket  is  then  folded  over  him,  with  others  added  if 
desired.  Hot-water  bottles  may  be  placed  at  the  feet  and 
cold  compresses  to  the  head.  The  patient  lies  in  this  for 
half  an  hour  and  is  then  rubbed  ofF. 

The  drip-sheet :  Have  a  basin  of  water  at  65°  F.  Put  in 
the  basin  a  sheet.     The  patient  stands  in  comfortably  hot 


76  THE  REST-TREATMJ^NT. 

water.  Have  ready  a  large  soft  towel  and  iced  water.  Wring 
out  the  towel  in  this  and  wrap  it  around  the  head  and  back 
of  the  neck.  Standing  in  front  of  tlie  patient,  the  sheet  is 
seized  by  the  two  corners  and  thrown  about  the  patient,  who 
holds  it  at  the  neck.  It  is  then  smoothed  out  over  the  body. 
It  is  then  dropped  and  the  patient  made  to  lie  down  on  a 
blanket,  which  is  wrapped  about  him.  Dry  thoroughly  with 
coarse  towels,  wrap  in  a  dry  blanket  for  a  time,  then  put  to 
bed.  The  water  should  be  gradually  cooled  day  by  day  to 
55°  F. 

The  bath,  pack,  and  drip-sheet  are  valuable  remedies  for 
insomnia. 

A  hot  .sifz-bath  consists  of  the  patient's  sitting  in  water  at  a 
temperature  of  100°  to  125°  F.  from  twenty  to  thirty  min- 
utes. 

Hot  compresses  are  often  used  for  the  relief  of  local  pains 
and  congestions. 

THE  REST-TREATMENT. 

This  method  of  treatment,  devised  by  S.  Weir  Mitchell,  is 
of  especial  value  in  neurasthenia  and  hysteria. 

Its  essential  features  are  :  isolation ;  absolute  rest ;  diet ; 
massage ;  electricity  ;  and  the  personal  influence  of  a  good 
nurse. 

Isolation  from  the  patient's  family  and  former  surroundings 
is  essential.  The  diet,  if  the  digestion  is  bad,  should  be  en- 
tirely of  milk.  Otherwise  easily  digested  solid  food  may 
alternate  with  it. 

Mest  must  be  absolute  in  severe  cases ;  even  sitting  up  in 
bed  should  not  be  allowed.  The  duration  of  the  treatment 
should  be  from  four  to  eight  weeks. 

The  following  schedule,  as  given  by  Dr.  J.  K.  Mitchell,  will 
illustrate  the  method : 

7.00  A.  M.  :  Cocoa  ;  cool  sponge-bath,  with  rough  rub  and 
toilet  for  the  day. 

8.00  A.  M. :  Milk.     Breakfast."     Rest  for  one  hour. 
10.00  A.  M.  :  8  oz.  peptonized  milk. 
11.00  A.  M.  :  Massage. 
12.00    M.     :  Milk  or  soup ;  reading  aloud  by  the  nurse. 


THE  REST-TREATMENT.     '  77 

1.30  p.  M.  :  Dinner  ;  rest  one  hour. 

3.30  p.  M. :  8  oz.  peptonized  milk. 

4.00  p.  M.  :  P^lcctricity  (general  faradization). 

6.00  1'.  M.  :  Supper,  with  milk. 

8.00  p.  M.  :    Reading  aloud  by  nurse  for  one-half  hour. 

9.00  p.  M.  :  Jjight  rubbing  by  nurse  with  drip-sheet. 
8  oz.  malt-extract  with  meals;  tonic  after    meals.      <S  oz. 
peptonized  milk  with  biscuit  at  bedtime,  and  a  glass  of  uiilk 
during  the  night  if  desired. 

This  may  be  modified  in  various  ways  according  to  the 
symptoms.  If  a  mild  case,  the  patient  may  be  allowed  to 
sit  up  for  a  few  hours,  or  even  go  out  for  a  drive. 


CHAPTER   y. 

SYMPTOMATIC   DISOEDEES. 

The  disorders  about  to  be  described  always  occur  as  symp- 
toms ;  but  as  symptoms  they  stand  out  so  prominently  as  to 
be  often  spoken  of  as  diseases  per  se. 

HEADACHE. 

Definition :  A  diffused  pain,  which  may  be  paroxysmal  or 
continuous,  affecting  different  parts  of  the  head,  and  not  con- 
fined to  the  seat  of  any  particular  nerve. 

Etiology :  The  causes  of  headache  are  many.  They  are 
conveniently  expressed  in  the  following  summai^y,  modified 
from  that  of  J.  C.  Wilson  : 

1.  Reflex  irritation — viz.,  ocular  (eye-strain) ;  nasal ;  pharyn- 
geal ;  auditory ;  decayed  teeth  ;  reproductive  organs  (especially 
female) ;  thoracic  and  abdominal  viscera. 

2.  Toxsemic : 

A.  Infections,  as  acute  infectious  diseases ;  malaria. 

B.  Incomplete  or  perverted  physiologic-chemical  processes,  or 
the  defective  elimination  of  waste :  as  ureemia ;  diabetes ; 
gout ;  lithsemia  ;  rheumatism  ;  gastro- hepatic  derangements  ; 
constipation. 

0.  Action  of  drugs  and  poisons : 

a.  Acute  :  nitrites  ;  quinine  ;  opium  ;  alcohol  ;  carbon  diox- 
ide, etc. 

6.  Chronic  :  lead  ;  tobacco  ;  alcohol ;  opium  ;  tea  ;  coffee. 

3.  Circulatory  disturbances  : 

A.  Pas.s'ire  congest/ on,  as  bv  ]X)sture  ;  tight  clothing  about 
the  neck  ;  j)r('ssiii'e  on  \ciiis  by  tumors. 

B.  Active  hype  rami  a,  from  excessive  pliysical  or  mental 
strain  ;  early  stage  of  a(;ute  meningitis. 

C.  Anam'ia,  following  loss  of  blood  or  the  idiopathic  anae- 
mias, especially  chlorosis. 

78 


HEADACHE.  79 

J).  Changes  in  the  arteries,  from  endarteritis ;  arterio-scle- 
rosis. 

4.  Neuroses,  as  epilepsy  ;  hysteria  ;  neurasthenia. 

5.  Organic  disease  of  the  brain  or  its  membranes — viz., 
meningitis,  syphilitic  or  otherwise;  abscess;  tumor;  aneu- 
rism. 

6.  Caries  of  the  cranial  bones. 

The  most  common  of  these  causes  are  eye-strain ;  gastro- 
hepatic  derangements ;  constipation ;  alcohol ;  uterine  dis- 
orders ;  anaemia ;  neurasthenia,  and  febrile  aifections.  Sev- 
eral of  these  may  coexist. 

Pathology  :  Of  the  exact  mechanism  of  the  production  of  a 
headache  we  know  nothing.  The  brain-substance  itself  is 
apparently  insensitive  to  direct  irritation,  but  processes 
which  irritate  sensory  nerves  in  any  part  of  their  course  may 
be  referred  to  the  cortical  centres  of  these  nerves  and  appre- 
ciated as  pain.  The  dura  is  sensitive  to  direct  irritation. 
Most  headaches  of  organic  orio-in  are  due  to  irritation  of  that 
membrane.  While  the  pain  in  the  majority  of  headaches 
appears  deep-seated,  in  some  cases  it  is  referred  to  the  scalp ; 
and  these  are  usually  associated  with  tenderness. 

The  origin  of  some  headaches  is  possibly  explained  by  the 
arrangement  of  the  nerve-supply  of  the  dura  and  scalp.  The 
supply  of  the  falx,  tentorium,  and  anterior  three-fourths  of 
the  dura  is  derived  from  the  fifth  nerve ;  the  posterior  fourth 
from  the  sensory  fibres  of  the  vagus.  The  scalp  as  far  back 
as  the  vertex  is  also  supplied  by  the  fifth,  the  remainder 
deriving  its  supply  from  the  posterior  branches  of  the  upper 
four  cervical  nerves. 

The  sensory  (descending)  root  of  the  fifth  nerve  is  in  close 
relation  with  the  origin  of  the  cervical  branches  in  the  cord  and 
of  the  cranial  nerves  in  the  medulla ;  the  regions  of  the  dura 
supplied  respectively  by  the  fifth  and  vagus  overlap ;  the 
vagus  furnishes  part  of  the  nerve-supply  of  the  viscera. 
These  relations  readily  account  for  the  fact  that  headache  is 
so  commonly  caused  by  irritative  conditions  in  other  organs. 

Headache  is  also  produced  by  anything  which  causes  in- 
creased blood-pressure  ;  all  headaches,  excepting  those  due  to 
impoverishment  of  the  blood-sup})ly,  are  made  worse  by  sud- 
den lowering  of  the  head. 


80  SYMPTOMATIC  DISORDERS. 

Headache — symptoms  :  The  pain  in  headache  often  differs 
in  character  and  location,  according  to  the  cause.  These 
facts,  while  not  absolute,  may  be  of  service  in  diagnosis.  It 
may  be  pulsating  or  throbbing ;  dull  and  heavy ;  constrict- 
ing or  pressing;  hot,  burning  or  sore;  boring  or  sharp. 

In  location  it  may  be  frontal,  occipital,  parietal  and  tem- 
poral; vertical,  diffused;  or  combinations  of  these. 

A  pulsating  or  throbbing  pain,  situated  either  in  the  ver- 
tex or  diff'used,  is  characteristic  of  that  due  to  circulatory  dis- 
turbances. The  dull,  heavy  pain,  often  frontal,  is  frequently 
found  in  toxic  headaches.  The  constricting  or  sense-of- 
pressure  type  is  common  in  neurasthenia.  Patients  often  de- 
scribe this  as  a  tight  band  being  drawn  about  the  head.  The 
hot,  burning  pain,  usually  vertical,  is  common  in  headaches 
due  to  anaemia.  The  shar})  boring  variety  is  found  in  the 
hysterical  and  neurotic.  It  is  often  described  as  a  nail  being 
driven  into  the  head,  and  is  then  called  the  clavus  hystericus. 

Headache,  due  to  eye-strain,  caused  by  hypermetropia, 
astigmatism,  or  lack  of  muscle-balance,  is  aggravated  by 
using  the  eyes,  and  is  associated  with  other  symptoms  of 
asthenopia. 

The  syphilitic  and  organic  headache  is  apt  to  be  markedly 
aggravated  at  night,  being  so  severe  as  to  prevent  sleep ; 
functional  headaches  rarely  do  this. 

Symptoms  which  commonly  accompany  headache  are  ver- 
tigo, nausea,  and  somnolence.  The  usual  symptoms  which 
accompany  the  condition  causing  the  headache  would  also  be 
present,  and  their  presence  would,  of  course,  be  of  assistance 
in  ascertaining  the  cause  of  the  pain.  In  examining  a  case 
of  chronic  headache  all  of  the  causes  detailed  above  must  be 
borne  in  mind,  and  careful  inquiry  made  as  to  the  condi- 
tion of  the  eyes ;  nose  ;  throat ;  teeth  ;  pelvic  organs,  if  a 
woman;  heart;  bloodvessels;  blood;  digestive  organs; 
habits  as  regards  alcohol,  tobacco,  etc. ;  and  the  possible 
existence  of  neurasthenia,  hysteria,  <»r  organic  disease  of  the 
brain  or  membranes. 

Diagnosis  :  Headache  must  be  distinguished  from  migraine 
and  neuralgia.  The  pain  of  headache  is  usually  bilateral, 
and  is  more  or  less  ])ersistenl  ;  th:it  of  migraine  is  jiarox- 
vsmal  and  unilateral,  and  is  associated  with  other  sensory  dis- 


MIGRAINE.  81 

turbances ;  it  passes  off,  leaving  the  patient  i'eeling  better 
than  before,  to  return  again  at  more  or  less  regular  intervals. 
The  pain  of  neuralgia  is  shooting  and  limited  to  the  course 
of  a  nerve,  along  which  there  are  often  tendei'  ])oints  (points 
of  Valleix). 

Having  determined  that  headache  is  the  condition  present, 
we  then  ascertain  to  which  of  the  causes  mentioned  above  it 
is  due. 

Treatment :  The  treatment  of  headache  is  essentially  that 
of  its  cause.  Various  measures,  however,  are  often  required 
for  the  immediate  relief  of  the  pain.  Antipyrin,  gr.  v-x, 
either  alone  or  combined  with  the  bromides  and  aromatic 
spirits  of  ammonia,  given  every  hour  until  two  or  three  doses 
are  taken  ;  phenacetin,  gr.  v— x,  repeated  in  an  hour  if  neces- 
sary ;  combinations  of  antifebrin,  gr.  ij-iij,  and  caffein,  gr. 
ss-j,  are  all  valuable.  Caffein  and  its  salts  are  especially 
beneficial  in  the  neurasthenic  headache.  Combinations  of 
caifein  and  ammonium  salicylate  may  prove  useful.  Fluid 
extract  of  ergot  in  doses  of  a  teaspoonful,  repeated  hourly 
until  three  doses  have  been  given,  is  recommended  in  cases 
in  which  there  is  vascular  engorgement. 

In  cases  due  to  constipation  and  gastro-hepatic  disturbance 
small  doses  of  calomel  and  bicarbonate  of  sodium  should  be 
given. 

Local  measures  are  sometimes  of  service  :  mustard  plasters 
to  the  nape  of  the  neck  ;  hot  and  cold  applications  ;  stimulat- 
ing liniments ;  menthol,  either  the  pencil  or  20  per  cent, 
solution  in  alcohol ;  a  tight  bandage  about  the  head,  may  all 
prove  useful. 

The  headache  of  arterial  sclerosis  is  often  benefited  by  the 
use  of  nitroglycerin.  Cases  are  reported  of  headache,  the 
cause  of  which  could  not  be  determined,  and  in  which  after 
all  other  measures  had  failed  the  i"emoval  of  a  button  of  bone 
by  the  trephine  has  afforded  relief.  These  measures  should 
all  be  associated  with  rest,  quiet,  and  light  diet. 

MIGRAINE. 

Definition  :  Migraine  is  more  than  lieadache,  but  may  be 
conveniently  (considered  here.     It  may  be  defined  as  a  consti- 

6— N.  \>. 


82  SYMPTOMATIC  DISORDERS. 

tutional  neurosis,  associated  with  violent  paroxysms  of  pain, 
usually  unilateral  and  confined  to  the  course  of  the  fifth 
nerve,  and  frequently  accompanied  with  other  sensory  dis- 
orders and  with  nausea  or  vomiting,  vaso-motor  disturbances 
and  mental  depression. 

Synonyms  :  Hemicrania  ;  sick  headache  ;  megrim. 

Etiology :  Migraine  is  a  disease  of  the  first  half  of  life, 
very  few  cases  beginning  after  thirty.  Heredity,  either  direct 
or  indirect,  is  the  most  important  predisposing  factor.  When 
direct,  members  of  the  family  for  several  generations  back 
have  been  afflicted.  When  indirect,  they  have  been  sufferers 
from  other  neuroses,  especially  neuralgia  or  epilepsy.  Fre- 
quently other  members  of  the  same  generation  are  sufferers 
either  from  migraine  or  one  of  the  neuroses  above  mentioned. 
The  gouty  diathesis  appears  to  have  some  influence  :  a  father 
may  be  gouty  and  the  son  have  migraine. 

In  some  cases,  when  the  disease  appears  late,  influences 
that  depress  or  weaken  the  nervous  system,  as  excessive  brain- 
work,  ansemia,  and  reflex  irritations,  seem  to  act  as  exciting 
causes.  In  those  who  are  already  sufferers,  an  attack  may  be 
precipitated  by  fatigue,  excitement,  digestive  disorders,  and 
eye-strain  either  by  over-use  or  watching  moving  objects. 

Migraine — symptoms :  In  a  typical  attack  the  patient  may 
or  may  not  have  for  a  day  or  so  prodromes,  as  a  feeling  of 
heaviness  in  the  head  and  somnolence.  Usually  the  onset  is 
sudden.  A  bright  spot  suddenly  appears  on  one  side  of  the 
visual  field,  which  enlarges,  becoming  darker  in  the  centre, 
and  changing  from  round  to  angular  and  zig-zag  shapes  (for- 
tification spectra).  In  ten  to  thirty  minutes  these  disappear, 
pallor  of  the  face  appears,  and  the  pain  begins  usually  in  one 
temple,  spreading  until  one  side  of  the  head  is  involved. 
The  pain  is  increased  by  noise,  light,  or  stooping,  but  feels 
better  when  a  recumbent  posture  is  maintained.  In  a  few 
hours  nausea  is  felt,  which  in  a  greater  or  less  length  of 
time  culminates  in  the  vomiting  of  first  the  stomach-contents, 
then  mucus  and  bile  ;  the  bile  being  due  to  retrostaltic  action 
of  the  stomach.  This  is  succeeded  by  sleep  and  relief  from 
pain.  The  attack  usually  lasts  about  twenty-four  hours,  but 
in  severe  cases  it  may  be  longer. 

The  pain,  while  usually  unilateral,  may  be  bilateral.     In- 


MIGRAINE.  83 

stead  of  the  form  of  sensory  disturbance  above  described, 
figures  of  men  and  animals  and  other  forms  of  visual  hallu- 
cination may  be  present.  In  other  cases  there  is  first  noticed 
dimness  of  sight  on  one  side,  which  increases  until  half  of 
each  field  is  blind  (homonymous  hemianopsia).  Karely,  in- 
stead of  visual,  disturbances  of  other  special  senses  occur,  as 
one-sided  deafness  ;  tinnitus ;  loss  of  taste  or  subjective  sen- 
sations of  taste.  Tingling  of  the  arm  followed  by  anaesthe- 
sia, or  vice  versa,  precedes  the  jjain  in  rare  instances.  Another 
rare  symptom,  occurring  when  the  pain  is  left-sided,  is  a 
transient  aphasia.  This  may  be  either  a  sensory,  motor,  or 
paraphasia.  This  symptom  may  be  associated  with  transient 
right-sided  tingling,  numbness,  or  motor  weakness  of  the 
arm  ;  more  rarely  of  the  leg.  There  may  also  be  mental 
depression,  restlessness,  and  either  temporary  loss  or  increase 
of  memory. 

The  vaso-motor  symptoms  are  usually  pallor  of  the  face 
and  coldness  of  the  extremities  ;  more  rarely  there  is  flushing 
with  sweating,  sometimes  unilateral ;  or  these  conditions  may 
alternate.     In  children  fever  is  often  present. 

The  attack  does  not  always  follow  the  type  above  described. 
Very  rarely  it  may  consist  of  some  of  the  various  sensory 
disturbances  described,  M'ith  very  little  or  no  pain  ;  or  of  that 
which  is  the  most  common  of  all  forms — i.  e.,  headache  asso- 
ciated with  vaso-motor  disturbance,  nausea,  and  vomiting. 

These  attacks  occur  from  two  weeks  to  a  month  apart. 
Patients  with  migraine  sometimes  suffer  from  vertigo  in  the 
intervals. 

Pathology  :  Migraine  possesses  no  morbid  anatomy.  It  is 
probably  due  to  periodical  "  discharges"  from  the  sensory 
centres  of  the  cortex,  similar  to  the  discharges  which  occur 
from  the  motor  centres  in  epilepsy.  The  relationship  between 
epilepsy  and  migraine  is  very  close.  In  those  instances  in 
which  diminished  function  (paresis,  hemianopsia)  occurs  there 
is  cortical  inhil/ition  preceding  the  discharge. 

Diagnosis :  The  distinctions  between  migraine,  headache, 
and  neuralgia  have  already  been  mentioned  (p.  80).  Those 
cases  in  which  there  are  disturbances  of  special  senses  with- 
out headache  closely  resemble  minor  epilepsy  with  a  visual 
or  other  special  sense-aura.     But  epilepsy  is  of  very  brief 


84  SYMPTOMATIC  DISORDERS. 

duration — a  few  seconds — while  the  disturbance  in  migraine 
lasts  twenty  to  thirty  minutes.  Epilepsy  and  migraine  may 
coexist. 

Prognosis  :  As  regards  life  the  prognosis  is  good.  As  re- 
gards ultimate  recovery  it  is  not  so  good ;  but  there  is  a 
tendency  for  the  attacks  to  diminish  in  the  second  half  of 
life  (the  menopause  in  women).  The  prognosis  is  better 
when  a  history  of  heredity  in  this  or  other  neurosis  is  not 
obtained.  It  is  also  more  favorable  when  the  disease  is  of 
recent  development.  In  the  majority  of  cases  much  can  be 
done  by  appropriate  measures  to  ameliorate  the  symptoms. 

Migraine — treatment :  Frojjhylaxis  is  of  importance.  The 
children  of  families  in  which  this  or  other  neurosis  exists 
should  be  carefully  watched.  All  possible  sources  of  reflex 
irritation  (eye,  nose,  digestive  organs)  should  be  avoided  or 
removed.  Excessive  mental  and  physical  strain  must  be 
avoided,  and  an  outdoor  and  regular  life  encouraged. 

Treatment  may  be  divided  into  that  of  the  attack  and  that 
of  the  disease. 

For  the  attack,  rest  in  bed  in  a  darkened  room  as  soon  as 
the  premonitory  symptoms  appear,  must  be  enjoined.  If 
possible,  the  stomach  should  be  washed  out  with  hot  water 
(105°  F.  or  more).  If  this  cannot  be  done,  large  quantities 
of  hot  water  should  be  drunk.  After  this  a  saline  cathartic, 
as  a  teaspoonful  or  two  of  Carlsbad  salts,  should  be  adminis- 
tered, the  action  of  which  may  be  hastened  by  a  hot  soap-and- 
water  enema.  Combined  with  these  measures  antipyrin, 
phenacetin,  acetanilid,  caffeine,  the  salicylates,  and  ergot,  and 
the  various  local  measures  may  all  be  tried,  as  recommended 
for  headache.  In  addition,  mild  galvanic  currents  applied 
to  the  head  and  static  sparks  are  sometimes  of  benefit. 

In  treating  the  disease  all  possible  sources  of  reflex  irrita- 
tion must  be  removed  ;  the  gastro-intestinal  tract  put  in  good 
condition  ;  and  the  diet  must  be  simple,  red  meats  aud  fermen- 
tative articles  being  avoided.  Of  drugs,  long-continued  courses 
of  cannabis  indica  to  point  of  toleration  are  most  successful. 
This  may  be  combined  with  arsenic ;  or,  if  there  is  a  gouty 
diathesis,  with  ammonium  salicylate  or  some  of  the  salts  of 
lithia.  Either  phospliate  of  sodium  or  Rochelle  salt  in  water 
before  breakfast  is  also  of  service.     Combined  with  the  use 


NEURALGIA.  85 

of  these  drugs,  should  be  tlie  measures  detailed  under  pro- 
phylaxis. 

NEURALGIA. 

Definition :  Neuralgia  is  a  functional  disease  of  the  sensory 
fibres  of  the  nerve-trunks,  and  is  characterized  by  pain 
(Sinkler). 

Forms :  Neuralgias  may  be  idiopathic  — /.  e.,  developed 
"  spontaneously  "  ;  or  symptomatic — /.  e.,  due  to  some  known 
cause.  According  to  their  location,  they  are  divided  into  :  tri- 
geminal, or  neuralgia  of  the  fifth  nerve  ;  sciatic  ;  intercostal ; 
cervico-occipital ;  brachial ;  lumbo-abdominal ;  crural ;  and 
visceral.  Trigeminal,  sciatic,  and  intercostal  are  by  far  the 
most  frequent. 

Etiology :  Neuralgia  is  a  disease  of  adults,  being  rare  in 
childhood  and  old  age.  Those  possessing  a  neurotic  consti- 
tution or  a  gouty  or  rheumatic  diathesis  are  especially  prone 
to  it.  It  is  more  common  in  cold  and  damp  climates,  and  in 
winter  than  in  summer.  The  exciting  causes  of  symptomatic 
neuralgia  are  exposure  to  cold  ;  toxsemias,  as  grippe  ;  uraemia ; 
gout ;  rheumatism  ;  malaria ;  diabetes ;  lead  and  other  metal- 
lic poisons  ;  anaemia  ;  debility  from  any  cause  ;  reflex  irrita- 
tions, as  eye-strain,  carious  teeth,  and  gastro-intestinal  de- 
rangements ;  neurasthenia  and  hysteria. 

Neuralgia — symptoms :  These  consist  of  paroxysms  of 
sharp,  shooting,  burning  pain  in  the  course  of  the  affected 
nerve.  In  the  intervals  between  the  paroxysms  there  may 
be  constant  dull  pain.  The  pain  is  increased  or  brought 
about  by  irritation,  as  by  cold,  heat,  or  pressure.  There  is 
frequently  hyperesthesia  in  the  region  of  the  affected  nerves  ; 
but  firm,  long-continued  pressure  may  give  relief.  In  some 
cases  tender  points  may  be  found  which  correspond  to  the 
exit  of  the  nerve  from  a  bone-canal  or  from  the  muscle  or 
fascia  (points  of  Valleix).  Vaso-motor,  secretory,  and  trophic 
disturbances  may  occur.  Frequently  the  paroxysms  may  re- 
cur at  the  same  time  each  day.  Now  and  then  we  meet  with 
a  hysteric  in  Avhom  a  painful  impression  remains  after  the 
true  paroxysm  has  passed  away  ;  this  is  called  "  reminiscent " 
or  "  hallucinatory  "  neuralgia. 

Pathology :  In  many  cases  of  so-called  neuralgia  there  is 


86  SYMPTOMATIC  DISORDERS. 

really  a  low-grade  neuritis.  This  is  especially  true  in  the 
trigeminal  and  sciatic  forms.  In  those  cases  due  to  toxEemias 
the  pain  is  probably  due  to  the  irritant  action  of  the  poison. 
That  due  to  anaemia  is  often  spoken  of  as  "  the  cry  of  the 
nerve  for  more  blood."  In  those  cases  in  which  no  cause  can 
be  traced  the  trouble  is  thought  to  be  due  to  some  derange- 
ment of  cells  constituting  the  spinal  or  cerebral  sensory 
neurons. 

Cases  ^  occurring  late  in  life  have  been  found  to  be  asso- 
ciated with  arterio-sclerosis.  In  a  number  of  Gasserian  gan- 
glia and  the  nerve-divisions  which  were  removed  by  Keen  for 
tic  douloureux,  Spiller  found  there  were  in  most  instances 
marked  evidences  of  degeneration  of  the  nerve-fibres  and 
ganglion-cells,  and  thickening  of  the  vessel-walls,  so  that  in 
some  instances  their  lumen  was  obliterated  (obliterating  ar- 
teritis). 

Diagnosis  :  We  have  already  spoken  of  the  features  which 
distinguish  neuralgia  from  headache  (p.  80).  The  diagnosis 
from  neuritis  would  depend  upon  the  facts  that  in  newitis  the 
pain  is  constant,  not  darting  and  shifting ;  there  is  tenderness 
along  the  whole  course  of  the  nerve,  made  worse  by  firm 
pressure  ;  there  is  frequently  anaesthesia,  and  motor  paralysis 
occurs. 

The  various  forms  of  neuralgia  will  be  discussed  under 
diseases  of  the  "  cranial  and  spinal  nerves,"  when  treatment 
will  also  be  discussed. 

PARESTHESIA. 

Definition :  The  general  term  "  parsesthesia "  has  already 
been  defined  (p.  43).  These  sensations  sometimes  confine 
themselves  to  a  certain  locality  or  occur  in  the  distribution 
of  a  certain  nerve,  and  may  be  then  considered  as  a  disease. 
When  the  feet  and  hands  separately  or  together  are  affected 
we  call  the  disorder  acroparcesthesia ;  when  it  only  occurs 
upon  rising  in  the  morning,  we  speak  of  wahing-numhness ; 
and  when  confined  to  the  distribution  of  a  particular  nerve, 
as  the  ulnar  or  external  cutaneous,  meralgia  paraesthetica  is 
the  term  used. 

1  Amer.  Jour.  Med.  Sci.,  1898,  p.  503. 


PARESTHESIA.  87 

Etiology  :  Par?estlicsia  may  occur  in  citlier  sex,  usually  after 
middle  life;  but  is  more  common  in  women,  being  especially 
frequent  in  women  during  the  menopause  and  in  those  who  do 
scrubbing,  Avashing,  and  sewing.  Those  of  either  sex  who 
are  obliged  to  be  upon  their  feet  a  great  deal  are  prone  to  it. 
The  gouty  or  rheumatic  diathesis  and  alcoholism  are  causes. 
It  has  followed  the  infectious  diseases. 

Parsesthesia — symptoms  :  These  consist  of  feelings  of  numb- 
ness, tingling,  or  coldness,  usually  beginning  in  the  hands, 
and  as  time  goes  by  the  arms,  feet,  and  legs  becoming  in- 
volved. These  symptoms  are  often  felt  just  after  aAvaking 
in  the  morning,  and  pass  oif  as  the  limbs  are  used  (w-aking- 
mimbness) ;  but  if  the  disorder  lasts  long  enough,  the  sensa- 
tions become  constant.  They  may  be  so  severe  as  to  awaken 
the  patient.  The  scalp  and  ears  may  rarely  be  affected. 
Cases  have  been  described  by  Roth,  Osier,  and  others  in 
which  a  burning  sensation  was  felt  in  an  area  about  the  size 
of  the  palm  of  the  hand  or  the  external  surface  of  the  thigh 
and  just  above  the  knee  (parsesthetic  meralgia).  This  form 
is  aggravated  by  standing.  There  is  usually  no  muscular 
weakness  or  anaesthesia,  but  a  clumsy  feeling  may  be  present 
in  the  fingers,  so  that  fine  movements  are  performed  with 
difficulty. 

In  tvaking -numbness  there  is  sometimes  temporary  weakness. 
General  restlessness  and  nervousness  are  usually  present.  The 
urine  may  be  excessive  in  amount  and  contain  large  amounts 
of  urates  or  phosphates.  Vaso-motor  symptoms,  character- 
ized by  local  congestions  and  sweating,  are  sometimes  seen. 

Pathology :  Parsesthesia  is  probably  due  either  to  a  poison 
circulating  in  the  blood,  which  irritates  the  sensory  nerve- 
endings  ;  or  to  a  disarrangement  of  the  blood-supply  to  the 
nerves,  either  hypersemia  or  anaemia.  In  some  cases  there  is 
most  likely  a  low  grade  of  neuritis. 

Paraesthesia — diagnosis :  The  condition  must  be  distin- 
guished from  neuritis  ;  organic  disease  of  the  brain  and  cord  ; 
hysteria  ;  neurasthenia  ;  and  Raynaud's  disease.  There  is  no 
tenderness  of  the  nerve-trunks,  muscular  paralysis  and 
atrophy,  or  anaesthesia,  which  we  find  in  neuritis.  Paraesthesia 
may  be  a  symptom  of  organic  disease  of  the  brain,  cord,  and 
peripheral  nerves  ;  of  neurasthenia  and  hysteria ;  but  when 


88  SYMPTOMATIC  DISORDERS. 

present  in  any  of  tliese  conditions,  other  symptoms  character- 
istic of  the  disorder  would  be  found,  and  the  paresthesia 
would  not  be  limited  in  distribution  and  constant  in  duration 
as  in  the  forms  we  have  described,  but  diffuse  and  temporary. 
Raynaud's  disease  is  cliaracterized  by  extreme  pallor  of  the 
affected  parts,  followed  by  congestion,  symptoms  which  are 
not  present  in  paresthesia. 

Prognosis :  The  disease  is  obstinate  to  treatment,  and  re- 
lapses are  apt  to  occur  ;  it  does,  however,  often  get  well.  It 
never  progresses  to  any  serious  disorder. 

Parsesthesia — treatment :  Ergot  in  large  doses,  long  con- 
tinued, as  recommended  by  Sinkler,  often  does  good.  Fara- 
dization and  massage  of  the  affected  limbs  are  of  service.  In 
those  cases  in  which  the  gouty  or  rheumatic  diathesis  is  sus- 
pected, salicylates,  lithia,  alkalies,  and  a  proper  diet  should 
be  advised.  Tonics,  as  strychnine,  arsenic,  mineral  acids, 
and  iron,  must  be  given  after  the  symptoms  subside  ;  and 
a  change  of  air  and  rest,  if  practicable,  be  secured.  In  ob- 
stinate cases  of  meralgia  paresthetica,  stretching  or  resection 
of  the  external  cutaneous  nerve  has  been  suggested  by  Spiller. 

VERTIGO. 

Definition :  Vertigo,  familiarly  spoken  of  as  giddiness  or 
dizziness,  is  the  consciousness  of  disturbed  equilibrium  due 
to  a  derangement  of  the  nervous  mechanism  which  governs 
the  relations  of  the  body  to  external  objects. 

Pathology :  For  the  securing  of  the  balance  or  equilibrium 
of  the  body  in  its  changing  relations  to  external  objects,  ac- 
curately timed  and  ever-changing  muscular  contractions  are 
necessary.  The  motor  impulses  necessary  to  cause  these 
contractions  are  determined  in  the  cortical  centres  by  certain 
sensory  impressions  which  are  constantly  being  received  for 
their  guidance.  These  impressions  are  derived  from  the  eye 
and  its  muscles  ;  the  semicircular  canals  of  the  internal  ear ; 
from  the  skin  of  these  parts  in  contact  with  external  objects ; 
and  from  the  articular  surfaces  and  muscles  about  them. 
Any  cause  which  disturbs  either  the  flow  or  reception  of 
sensory  impulses  from  these  sources  causes  a  derangement  in 
time  and  force  of  the  motor  impulses.     This  is  manifested  by 


VERTIGO.  89 

vertigo.  The  nausea,  vomiting,  and  irregular  pulse  are  due 
to  reflex  irritation  of  the  vagus  nerve. 

Etiology :  The  eauses  of  vertigo  are  :  (1)  Visual  defects,  as 
refractive  errors  and  loss  of  muscle-balance.  (2)  Aural  dis- 
turbances, as  either  disease  of  the  labyrinth  (Meniere's  disease) 
or  inflammatory  conditions  of  the  middle  ear,  causing  irritation 
of  the  auditory  nerve-endings  in  the  labyrinth.  (3)  Toxa^nic 
conditions,  as  at  the  onset  of  infectious  diseases ;  alcohol, 
tobacco,  lithsemia,  dyspepsia,  constipation.  (4)  Causes  which 
produce  derangements  of  the  cerebral  circulation,  as  arterio- 
sclerosis, hypersemia,  anaemia,  valvular  disease  of  the  heart, 
and  fatty  heart.  (5)  Neuropathic  conditions,  as  neurasthenia, 
hysteria.  (6)  Organic  disease  of  the  brain,  especially  of  the 
cerebellum  and  its  peduncles.  (7)  Mechanical  causes  which 
produce  disarrangement  of  the  fluid  in  the  semicircular  canals, 
as  swinging ;  sea- voyages  (sea-sickness);  rotary  movements,  etc. 

In  a  few  cases  no  cause  can  be  detected  ;  these  are  known  as 
"  essential  vertigo." 

General  symptoms:  An  attack  of  vertigo  comes  on  sud- 
denly, and  as  a  rule  is  of  momentary  duration.  Objects  seem 
to  whirl  about  the  patient ;  the  floor  or  bed  rises  or  sinks 
(objective  vertigo) ;  or  the  patient  himself  feels  as  if  he  were 
whirling  rapidly  about  (subjective  vertigo).  There  is  apt  to 
be  mental  confusion,  but  rarely  loss  of  consciousness ;  the 
patient  totters  and  sometimes  falls  ;  there  may  be  nausea  and 
vomiting,  and  irregular  pulse  often  occurs  in  severe  attacks. 
In  attacks  due  to  toxic  substances,  as  alcohol,  tobacco,  and 
other  narcotics,  the  vertigo  is  apt  to  last  a  considerable  time. 
Sudden  rising  or  other  movements  may  increase  the  vertigo. 
Attacks  may  sometimes  be  produced  when  the  head  is  held  in 
certain  positions.     Auditory  vertigo  deserves  special  mention  : 

Auditory  vertigo :  Inflammatory  conditions  of  the  middle 
ear  or  impacted  cerumen  in  the  canal  may  produce  vertigo. 
They  possibly  do  this  by  causing  irritation  of  the  auditory 
nerve-endings,  and  in  some  instances  by  the  pressure  of  the 
stapes  upon  the  labyrinthine  fluid.  These  forms  must  not  be 
confounded  with 

Meniere's  disease,  which  is  due  to  primary  disease  of  the  in- 
ternal ear  involving  the  end-organs  of  the  eighth  nerve  in 
the  labyrinth.     The  lesion  in  chronic  cases  may  be  caused  by 


90  SYMPTOMATIC  DISORDERS. 

exposure  to  cold,  gout,  or  syphilis  ;  or  to  atrophy  of  the  audi- 
tory nerve.     Some  of  the  acute  cases  are  due  to  hemorrhage. 

The  affection  is  rare  in  early  life.  The  patient  suffers 
from  deafness  of  nerve-origin ;  tinnitus  ;  and  paroxysms,  oc- 
curring at  regular  intervals,  of  intense  vertigo.  The  erect 
posture  is  impossible,  and  the  recumbent  position  even  does 
not  relieve  it.  The  paroxysm  is  usually  terminated  by  nausea 
or  vomiting,  and  sometimes  syncope.  The  paroxysms  may 
occur  daily,  or  weeks  may  intervene. 

The  acute  or  apoplectiform  attacks  begin  suddenly  with 
tinnitus  and  paroxysms  of  vertigo  as  just  described.  In  the 
intervals  there  is  apt  to  be  impairment  of  equilibrium,  so  that 
the  patient  walks  with  difficulty.  The  prognosis  is  uncertain. 
A  small  proportion  of  cases  may  recover  with  total  loss  of 
hearing  on  the  affected  side.  In  the  majority  of  instances 
the  disease,  with  intervals  of  improvement,  continues  through 
life. 

Vertigo — diagnosis :  The  presence  of  the  symptom  usually 
may  be  recognized  without  difficulty.  In  some  instances  the 
possibility  of  the  attack  being  due  to  epilepsy  in  the  form  of 
petit  mal  must  be  considered.  In  this,  however,  loss  of  con- 
sciousness can  always  be  discovered ;  the  attack  is  of  shorter 
duration ;  and  giddiness,  nausea,  and  vomiting  are  not  pres- 
ent as  in  vertigo.  The  cause  must  always  be  determined  if 
possible.  This  is  done  by  a  careful  physical  examination  of 
the  heart,  eyes,  ears,  bloodvessels,  etc.,  of  the  patient  and 
inquiry  into  the  associated  symptoms.  The  possibility  of 
epilepsy  must  be  borne  in  mind. 

The  prognosis  depends  upon  the  cause.  If  that  can  be 
corrected,  it  is  good.  In  that  due  to  organic  brain  disease  or 
Meniere's  disease,  it  is,  of  course,  not  favorable. 

Treatment :  The  treatment  of  vertigo  consists  of  (1)  that 
of  the  attack  ;  (2)  that  of  the  cause. 

The  attack  is  best  treated  by  rest  in  the  recumbent  position, 
and  the  administration  of  aromatic  spirits  of  ammonia  and 
the  bromides. 

In  3fSniere's  disease  quinine  in  ascending  doses  until  cin- 
chonism  results,  when  the  drug  is  stopped  for  a  time  (Char- 
cot). Or  the  use  in  moderate  doses  of  the  salicylates  may  be 
tried.     Sinkler  recommends  the  long-continued  use  of  ergot 


INSOMNIA.  91 

and  cannabis  indica.  The  continuous  use  of  the  bromides 
and  the  hypodermatic  injection  once  daily  (Hirt)  of  ten  drops 
of  a  2  per  cent,  solution  of  pilocarpine  have  been  of  service. 
Vertigo  due  to  either  arterio-sclerosis  or  senility  is  bene- 
fited by  nitroglycerin  and  potassium  iodide.  The  treatment 
of  the  other  forms  consists  of  the  removal  of  the  cause,  when 
possible. 

INSOMNIA. 

Definition :  Insomnia  is  the  term  used  to  designate  a  condi- 
tion characterized  by  habitual  incomplete  sleep,  or  by  periods 
of  entire  absence  of  normal  sleep. 

Etiology :  The  physiology  of  sleep  is  not  well  nnderstood. 
It  has  been  found  that  during  sleep  there  is  ansemia  of  the 
brain  accompanied  by  dilatation  of  the  bloodvessels  of  the 
limbs  ;  but  as  anaemia  from  disease  does  not  canse  an  excessive 
desire  for  sleep,  it  is  evident  that  this  is  not  the  cause.  Wil- 
cox advances  the  view  of  Rabl-Ruckhard  that  sleep  is  due  to 
a  retraction  of  the  dendritic  processes  of  the  neuron,  which, 
of  course,  would  prevent  for  the  time  being  communication 
between  the  different  parts  of  the  nervous  system  and  inter- 
change of  nerve-impulses. 

Symptomatology :  Insomnia  may  be  a  symptom  of  any  of 
the  organic  and  functional  diseases  of  the  nervous  system. 
It  is  especially  common  in  the  neurasthenic  and  overworked. 
It  is  also  a  symptom  of  disordered  action  of  other  organs — 
viz.,  in  toxic  states  of  the  blood  from  infectious  disease ; 
kidney  diseases ;  lithsemia ;  or  drugs,  as  tea,  coffee,  alcohol ; 
and  in  diseases  of  the  heart  and  bloodvessels. 

Its  prolonged  presence  causes  mental  depression  and  irri- 
tability. 

Insomnia — treatment :  Treatment  should,  of  course,  be 
directed  to  the  cause  of  the  symptom  when  it  can  be  ascer- 
tained. In  treating  insomnia  drugs  should  be  avoided  when 
possible. 

Often  one  of  the  following  measures,  used  before  retiring, 
will  answer  :  muscular  exercise  ;  massage  ;  a  cup  of  hot  milk 
or  bouillon  ;  or  a  hot  bath  (104°  F.),  continued  until  the  cuta- 
neous surface  is  reddened.  A  season  of  camp-life  may  bring 
relief  when  all  else  fails. 


92  SYMPTOMATIC  DISORDERS'. 

When  drugs  are  required,  one  of  the  best  is  trional,  gr. 
XV— XXX  in  hot  milk,  an  hour  or  two  before  bedtime.  Chloral, 
gr.  XV— XX,  or  by  the  method  of  Ringer,  gr.  v  every  half- 
hour  until  four  or  five  doses  are  taken,  is  of  much  service. 
Sulphonal,  paraldehyde,  and  chloralose  are  also  of  use. 
When  accompanied  by  excitement  or  agitation  hydrobromate 
of  hyoscine,  gr.  yq-q,  repeated  every  four  hours  as  required, 
is  most  useful.  Opium  should  never  be  prescribed  for  in- 
somnia unless  caused  by  pain.  To  avoid  the  formation  of 
drug-habits,  whatever  drug  is  used,  it  is  well,  if  possible,  to 
prevent  the  patient  from  either  knowing  what  it  is  or  being 
able  to  renew  the  prescription. 


CHAPTER    VI. 

DISEASES  OF  THE  PERIPHERAL  NERVES. 
COMPRESSION-  OR  PRESSURE-PALSY. 

Definition :  Pressure-pulsy  is  a  paralysis  of  certain  muscles 
clue  to  long-continued  pressure  upon  tiie  nerve  supplying 
them. 

Symptoms :  When  a  nerve-trunk  is  subjected  to  slight 
pressure,  if  long  continued,  numbness,  tingling,  and  a  feeling 
of  heaviness,  and  at  times  transient  inability  to  move  the 
limb  are  experienced.  These  sensations  are  familiar  to  all, 
and  are  commonly  described  by  saying  that  the  part  is 
"asleep."  When  the  pressure  is  more  pronounced  or  of 
longer  duration  the  symptoms  do  not  pass  away,  and  a 
paralysis  of  the  muscles  supplied  by  the  compressed  nerve 
results.  The  musculo-spiral,  from  the  frequent  habit  of 
sleeping  with  the  head  resting  upon  the  arm,  is  especially 
liable  to  receive  pressure,  and  is  the  nerve  most  commonly 
affected.  A  history  of  previous  indulgence  in  alcohol  is  fre- 
quent in  these  cases.  Other  nerve-trunks  that  are  more  or 
less  commonly  affected  are  the  ulnar,  sciatic,  and  anterior 
tibial.  The  patient  complains  of  a  feeling  of  numbness  and 
inability  to  use  the  muscles.  There  is  no  tenderness  over  the 
nerve-trunk,  and  usually  no  anaesthesia.  Atrophy  takes 
place,  but  it  is  not  excessive  as  a  rule.  The  electrical  reac- 
tions are  either  normal  or  in  aggravated  cases  there  is  a 
quantitative  decrease  to  galvanism  and  faradism. 

Pathology  :  The  compression,  in  producing  these  symptoms, 
acts  by  separating  the  molecular  elements  of  the  white  sub- 
stance, and  setting  up  a  secondary  degeneration  of  the  same 
character  as  results  from  the  division  of  a  nerve  (Gowers). 

The  diagnosis  of  pressn re-palsy  is  based  u])()n  the  discovery 
that  pressure,  as  from  crutches,  sleeping  with  the  head  upon 

93 


94  DISEASES  OF  THE  PERIPHERAL  NERVES. 

the  arm,  etc.,  has  been  exerted  upon  the  nerve.  The  absence 
of  pain  and  tenderness  distinguishes  the  condition  from  neu- 
ritis. When  the  musculo-spiral  nerve  is  the  seat  of  the 
trouble  neuritis  due  to  lead  might  be  thought  of;  but  the 
absence  of  other  symptoms  of  lead-poisoning  and  the  usual 
unilateral  paralysis  distinguish  it  from  that. 

Pressure-palsy — treatment :  Measures  to  promote  the  nutri- 
tion of  the  muscles,  as  electricity,  massage,  and  strychnine, 
either  hypodermatically  or  by  the  mouthy  are  indicated. 

NEURITIS,  OR  INFLAMMATION  OF  NERVES. 

Neuritis  may  be  confined  to  a  single  nerve-trunk  and  be 
local ;  or  a  number  of  nerves  may  be  affected,  when  it  is 
termed  multiple.  It  may  be  interstitial  or  parenchymatous. 
It  may  be  either  acute  or  chnmic.  The  acute  form  often  has 
a  tendency  to  subside  into  the  chronic. 

Morbid  anatomy :  Inflammation  of  a  nerve  may  be  inter- 
stltialy  in  which  the  connective  tissue  is  the  primary  seat  of  the 
process  ;  or  parenchymatous,  wlien  the  nerve-fibres  are  dis- 
eased without  involvement  of  the  connective  tissue. 

In  acute  interstitial  neuritis  the  changes  occur  in  the  peri- 
neurium and  endoneurium.  The  nerve  is  soft,  swollen,  and 
reddish  in  color.  Microscopically  we  find  the  bloodvessels 
distended  ;  infiltration  of  round  cells  between  the  nerve-bun- 
dles ;  and  the  perineurium  and  connective-tissue  trabeculse 
are  increased  in  size.  In  very  advanced  forms  partially  de- 
generated fibres,  with  flitty  myelin-sheaths,  and  swollen  axis- 
cylinders,  are  found  ;  ultimately  the  nerve-fibres  may  be  de- 
stroyed. The  changes  in  the  nerve-fibres  are  secondary  to 
those  in  the  connective  tissue. 

Chronic  interstitial  neuritis  may  follow  the  acute  form  or 
occur  independently.  The  nerve  is  hard,  the  connective 
tissue  increased  ;  the  bloodvessel-walls  are  thickened,  their 
lumen  sometimes  obliterated  ;  and  more  or  less  round-cell  in- 
filtration is  found  in  the  connective  tissue.  The  nerve-fibres 
are  degenerated,  and  many  of  them  have  disappeared.  Fre- 
quently there  is  proliferation  of  the  cells  in  the  neurilemma. 
Ascending  degeneration  in  the  ]>osterior  columns  of  the  cord 
and  changes  in  the  o;ano'lion-cells  are  often  found. 


LOCALIZED  NEURITIS.  95 

In  parenchymatous  neuritis  we  lind  the  nerve-trunks 
slightly  firmer  and  grayer  than  nornial.  The  usual  evidences 
of  inflammation  are  absent ;  the  myelin  is  segmented  and 
divided  into  drops  and  granules ;  and  the  axis-cylinders  are 
granular,  subdivided,  and  finally  disLip])ear.  The  nuclei  on 
the  sheath  of  Schwann  proliferate,  and  finally  the  nerve  be- 
comes a  fibrous  cord.  Changes  are  frequently  found  in  the 
anterior  ganglion-cells  in  the  cord  (reaction  at  a  distance). 

Localized  Neuritis. 

Etiology :  Localized  neuritis  arises  from  :  (1)  Exposure  to 
cold.  (2)  Traumatism,  as  wounds  ;  blows  upon  the  nerve  ; 
the  tearing:  and  stretchino-  v.diich  follow  a  dislocation  or  fract- 
ure  ;  and  electrical  shock.  (3)  The  extension  of  inflamma- 
tion from  neighboring  parts,  as  neuritis  of  the  facial  nerve 
due  to  inflammation  of  the  middle  ear ;  septic  wounds  of  the 
extremities,  etc. 

Localized  neuritis  is  usually  interstitial. 

Localized  neuritis — symptoms:  Slight  constitutional  dis- 
turbances may  be  present.  A  most  prominent  symptom  is 
pain  in  the  course  of  the  nerve  and  parts  to  Avhich  it  is  dis- 
tributed. This  is  of  a  burning,  boring  character,  worse  at 
nights  and  increased  by  movements  of  the  atfected  part.  The 
nerve  is  tender  when  pressed  upon.  Occasionally  redness  of 
the  skin  over  it  and  ojdema  are  present.  The  function  of 
the  muscles  supplied  by  the  affected  nerve  is  impaired,  and 
they  become  flaccid  and  finally  atrophy.  Changes  in  their 
response  to  the  electrical  currents,  varying  from  a  quantita- 
tive decrease  in  mild  cases  to  a  typical  DeR,  are  found.  At 
the  onset  muscular  twitchings  are  sometimes  noticed.  Vari- 
ous parsesthetic  sensations  are  experienced.  Hypersesthesia 
may  be  present,  and  after  a  time  sensation  may  be  lessened, 
or  total  anaesthesia  in  small  areas  is  found.  The  skin  be- 
comes atrophied  and  glossy,  or  more  rarely  thickened,  and 
the  nails  are  ridged  and  brittle.  Increased  perspiration  has 
been  observed.  These  symptoms  vary  in  severity  according 
to  the  acuteness  of  the  process. 

Constitutional  s}'mptoms  are  absent  in  subacute  and  chronic 
cases,  the  pain  and  tenderness  usually  are  not  so  severe,  and 


96  DISEASES  OF  THE  PERIPHERAL  NERVES. 

ill  tlie  latter,  when  it  does  not  follow  an  acute  attack,  the 
development  of  the  symptoms  is  gradual.  In  these,  contract- 
ures due  to  overaction  of  sound  muscles  may  develop. 
When  the  inflammation  is  confined  to  the  connective  tissue 
and  there  is  not  much  exudation,  the  function  of  the  nerve- 
fibres  is  not  much  impaired.  In  these  cases  pain  and  ten- 
derness may  be  the  only  symptoms  noticeable,  but  careful 
examination  will  also  show  some  flaccidity  and  weakness  of 
the  muscles.  The  inflammation,  especially  Avhen  due  to 
traumatism,  at  times  may  extend  up  the  nerve-trunk  and 
involve  other  nerve-trunks  in  communication  with  it.  At 
times  the  spinal  cord  may  be  reached  and  meningitis  or 
myelitis,  or  both^  be  produced.  This  is  known  as  ascending 
'neuritis. 

The  duration  of  a  neuritis  may  vary  from  a  few"  weeks  in 
mild  cases  to  months  and  even  years.  Traumatic  neuritis 
is  .especially  liable  to  become  "  ascending." 

Localized  neuritis — diagnosis :  From  the  ordinary  rheu- 
matic attack  localized  neuritis  is  differentiated  by  the  local- 
ization of  the  pain  and  tenderness  to  the  course  of  a  nerve, 
and  the  impairment  of  function  of  the  muscles  supplied  by 
this  nerve.  In  this  connection  it  must  be  remembered  that 
in  very  acute  attacks  the  pain  may  be  diffuse  and  the  muscles 
tender ;  but  investigation  of  the  nerve-trunks  and  the  quickly 
resulting  muscular  disability  and  atro^^hy  will  settle  the 
question. 

Chronic  neuritis,  especially  those  mild  cases  in  which  the 
motor  symptoms  are  not  marked,  may  be  mistaken  for  neu- 
ralgia ;  but  in  neuritis  pain  and  tenderness  of  the  nerve  are 
constant ;  in  neuralgia  the  pain  is  darting  and  paroxysmal, 
and  tenderness,  when  present  at  all,  is  so  only  during  par- 
oxysms and  is  confined  to  spots  of  definite  localization  (tender 
points  of  Valleix).  In  neuritis  there  is  usually  some  degree 
of  weakness  and  flaccidity  of  the  muscles  ;  in  neuralgia  there 
is  none. 

The  pains  due  to  some  cord-diseases  may  simulate  neuritis  ; 
but  there  are  not  local  tenderness  of  the  nerve  and  limitation 
in  distribution  to  a  single  nerve. 

Prognosis:  This  is  always  doubtful.  Apparently  mild  cases 
are  often  intractable  to  treatment.     The  gravest  forms  are 


LOCALIZED  NEURITIS.  97 

those  due  to  secondary  infection  from  a  local  suppurative  in- 
flammation. As  the  symptoms  are  more  intense,  especially 
the  evidences  of  neural  degeneration  as  seen  by  muscular 
atrophy  and  well-marked  DeR,  the  prognosis  becomes  worse. 
In  neuropathic  subjects  the  pain  is  apt  to  remain  even  after 
all  other  symptoms  have  vanished.  Ascending  neuritis  is 
always  most  obstinate. 

Localized  neuritis — treatment :  In  acute  neuritis  rest  of  the 
part  where  the  inflamed  nerve  is  situated  is  of  first  impor- 
tance. For  the  relief  of  pain  antipyrin,  phenacetin,  and  like 
drugs  can  be  administered  and  the  part  wrapped  in  hot  lead- 
water  and  laudanum  or  other  hot  applications.  Care  must  be 
taken  not  to  blister  the  skin  with  these,  as  troublesome  sores 
may  remain.  If  the  patient  is  gouty  or  rheumatic,  salicy- 
lates in  full  doses  should  be  administered.  In  the  author's 
experience  one  of  the  most  efficient  means  for  the  relief  of 
pain  is  the  passage  of  a  constant  galvanic  current  down  the 
course  of  the  nerve  for  ten  or  fifteen  minutes  daily.  In  some 
cases  this  may  aggravate  the  pain,  when  it  should  be  discon- 
tinued. 

After  the  more  acute  symptoms  have  subsided,  vigorous 
counterirritation  by  means  of  fly-blisters  or  the  cautery 
should  be  substituted  for  the  lead- water  and  laudanum.  In 
this  stage  the  use  of  the  extreme  dry  heat  (250°-300°  F.), 
applied  by  an  apparatus  devised  for  that  purpose,  is  useful. 

When  the  acute  stage  is  past  or  has  subsided  into  the 
chronic,  in  conjunction  with  counterirritation,  measures  to 
promote  the  nutrition  of  the  muscles — viz.,  massage,  elec- 
tricity, and  strychnine,  preferably  hypodermically — must  be 
employed.  In  ascending  neuritis  vigorous  counterirritation 
should  be  maintained  above  the  area  of  inflammation ;  and 
the  question  of  resection  of  the  nerve  or  even  amputation 
above  the  seat  of  inflammation  may  sometimes  have  to  be 
considered. 

Neuritis  of  some  special  nerves  may  demand  some  modifi- 
cation or  addition  to  this  treatment,  which  will  be  described 
when  we  describe  the  diseases  of  these  nerves. 
7— N.  D. 


98  DISEASES  OF  THE  PERIPHERAL  NERVES. 


Multiple  Neuritis. 

Etiology :  Multiple  neuritis  is  probably  always  due  to  the 
influence  of  a  poison  circulating  in  the  blood ;  although  in 
some  cases  we  may  be  unable  to  determine  its  nature.  These 
causes  are  expressed  in  the  following  table,  modified  from  that 
of  Ross : 

I.  Idiopathic  form  (due  to  an  unknown  poison) :  a,  acute; 
b,  subacute  ;  c,  chronic  form  ;  d,  recurrent. 

II.  Poisons  introduced  from  without:  a.  diffusible  stimu- 
lants— alcohol ;  carbon  monoxide  ;  carbon  bisulphide  ;  dinitro- 
benzine ;  aniline,  b.  Infectious  diseases:  diphtheria;  influ- 
enza ;  typhoid  fever ;  scarlatina ;  measles  ;  pertussis,  etc. ; 
septicsemia  ;  syphilis  ;  tuberculosis  ;  pneumonia  ;  malaria ; 
beri-beri ;  leprosy,  c.  Metallic  poisons :  lead,  arsenic ;  mer- 
cury ;  phosphorus  ;  silver,     d.  Ptomains} 

III.  Poisons  produced  ivithin  the  body :  Gout ;  rheumatism  ; 
pregnancy  and  the  puerperal  state  ;  chorea ;  diabetes. 

IV.  The  dyscrasic  form :  Chlorosis ;  marasmus ;  cancer 
and  other  forms  of  cachexia ;  vascular  degenerations. 

Multiple  neuritis  may  occur  at  any  age. 

Morbid  anatomy  :  The  inflammation  in  these  cases  is  almost 
invariably  of  the  parenchymatous  variety. 

Multiple  neuritis — symptoms :  All  of  the  causes  above  men- 
tioned do  not  produce  similar  symptoms.  From  some,  sen- 
sory nerve-fibres  especially  suffer ;  from  some,  the  motor ; 
while  from  others  both  motor  and  sensory  fibres  are  alike 
affected.  Again,  certain  poisons  seem  to  have  a  predilection 
for  certain  nerve-trunks ;  for  instance,  that  of  lead  for  the 
musculo-spirals.  For  these  reasons  we  have  certain  types 
due  to  certain  causes,  these  types  being  sufficiently  constant 
to  enable  us  in  many  cases  to  be  almost  positive  of  the  cause 
from  the  symptoms  produced. 

Some  of  the  causes  mentioned  are  but  rarely  the  cause  of 
neuritis,  both  because  the  individual  is  infrequently  brought 
under  the  influence  of  many  of  them,  and  because  the  nerves 
seem  to  be  more  susceptible  to  the  toxic  influence  of  some 

^  Spiller  (Phila.  Polyclinic,  vol.  vii.  p.  455)  has  recently  reported  a  case 
of  multiple  neuritis  due  to  the  ingestion  of  putrefying  pork. 


MULTIPLE  NEURITIS.  99 

than  of  others.  Only  the  more  common  forms  will  be  here 
described. 

Idiopathic  multiple  neuritis :  This  may  occur  at  all  ages 
from  infancy  to  old  age,  the  majority  of  the  cases  occurring 
during  middle  life.  In  some  cases  it  appears  to  follow  chill- 
ing of  the  body  after  being  overheated  or  exposure  to  cold. 
In  most  of  them  no  cause  can  be  ascertained.  The  attack 
usually  begins  with  a  chill  followed  by  rise  of  temperature, 
pain  in  the  back  and  limbs,  headache,  and  general  malaise. 
Parsesthetic  sensations  are  felt  in  the  hands  and  feet ;  the 
skin  may  be  hypersesthetic  and  the  muscles  and  nerves  are 
tender. 

Loss  of  power  soon  becomes  manifest.  It  usually  begins 
in  the  flexors  of  the  feet  and  extends  upward  ;  more  rarely 
the  arms  may  be  first  involved.  The  paralysis  extends  until 
in  severe  cases  the  muscles  of  the  trunk  and  those  of  respi- 
ration are  involved.  Atrophy  of  the  muscles  occurs  early ; 
the  deep  reflexes  are  lost ;  those  of  the  skin  may  be  present 
or  not.  In  the  early  stages  there  is  merely  a  more  or  less 
quantitative  decrease  in  the  response  of  the  muscles  to  the 
faradic  current.  As  the  disease  progresses  partial  reactions 
of  degeneration  may  be  found.  There  may  or  may  not  be 
areas  of  anaesthesia  present. 

Recurrent  multiple  neuritis:  In  1891  Dr.  Mary  Sherwood 
reported  two  cases  in  which,  without  apparent  cause,  the 
patients  had  had  several  attacks  of  neuritis.  Since  then  a 
few  others  have  been  reported,  the  last  being  by  H.  M. 
Thomas,  whose  case  was  then  in  the  fifth  attack  of  multij^le 
neuritis.  The  symptoms  of  these  cases  are  the  ordinary  ones. 
It  has  been  noted  that  rarely  patients  who  have  had  lead- 
neuritis,  have  recurrences  without  renewed  exposure.  No 
evidences  of  lead,  however,  were  present  in  most  of  the 
cases  reported  as  recurrent  neuritis,  and  the  cause  of  these 
attacks  remains  doubtful. 

Alcoholic  multiple  neuritis :  Alcohol  is  a  frequent  cause  of 
neuritis.  It  is  more  apt  to  occur  in  persons  who  drink 
steadily  than  those  who  indulge  in  periodical  sprees.  Women 
appear  to  be  especially  lialde. 


100         DISEASES  OF  THE  PERIPHERAL  NERVES. 

The  first  symptoms  are  sensory  disturbances,  pain  in  the 
extremities,  with  pins-and-needles  sensations,  and  a  feeling 
of  numbness.  There  is  marked  hypersesthesia  of  the  calf- 
muscles.  Muscular  weakness  soon  appears,  the  extensors  of 
the  feet  being  usually  first  aifected,  those  of  the  hands  soon 
following.  Double  foot-drop  and  wrist-drop  are  then  pro- 
duced.    The  former  is  a  most  characteristic  symptom  of  the 

Fig.  26. 


•in. 


Multiple  neuritis.    Double  wrist-drop  and  double  foot-drop  (Lloyd). 

disorder  (see  Fig.  26).  Eventually  the  other  muscles  of  the 
limbs  become  paralyzed.  The  motor  cranial  nerves  may  be- 
come affected,  and  rarely  the  optic.  The  sphincters  are  not 
involved.  Marked  muscular  atrophy  soon  ensues,  and 
changed  electrical  reactions,  from  quantitative  decrease  to 
reactions  of  degeneration  of  varying  degrees,  are  present. 
The  knee-jerk  is  lost  early ;  the  skin-reflexes  are  usually 
active.  Severe  pain  is  always  present ;  the  nerve-trunks  and 
muscles  are  exceedingly  tender,  the  latter  more  so  than  in 
any  other  form  of  neuritis,  and  the  skin  is  hypersesthetic. 
Trophic  symptoms  are  rare,  but  glossy  skin  and  roughening 
of  the  nails  may  occur.  Excessive  sweating  is  sometimes 
seen.  In  severe  cases  there  are  elevation  of  temperature, 
the  pulse  is  rapid  and  weak,  and  the  capillary  circulation  bad. 
Mental  symptoms,  evidenced  by  delirium,  hallucinations,  de- 
lusions of  grandeur,  confusion  and  loss  of  memory,  are  pres- 
ent,    In  most  cases  the  mental  symptoms  do  not  resemble 


DIPHTHERITIC  NEURITIS.  101 

delirium  tremens,  but  it  should  be  remembered  that  it  may 
coexist. 

When  the  patient  becomes  able  to  walk  the  gait  is  charac- 
teristic ;  owing  to  the  foot-drop  the  knees  must  be  lifted  high 
in  order  to  clear  obstacles — the  so-called  "  steppage  "  gait. 
Incoordination  may  then  be  also  a  feature,  and  the  disease  is 
then  sometimes  known  as  pseudotabes.  . 

Multiple  neuritis  from  lead :  This  form  is  peculiar  in  that 
the  musculo-spiral  nerves  are  usually  the  first  to  be  affected, 
causing  paralysis  of  the  extensors  of  the  wrist  and  fingers 
(see  p.  154).  For  some  unknown  reason  the  spinator  longus 
and  the  extensor  ossis  metacarpi  pollicis,  also  supplied  by 
this  nerve,  escape.  One  arm,  usually  the  right,  may  be 
affected  first ;  but  the  other  soon  follows,  and  the  patient  in  a 
short  time  has  a  double  wrist-drop,  atrophy  of  the  affected 
muscles  rapidly  occurs,  and  the  reaction  of  degeneration  in 
various  degrees  is  present.  The  supinator  longus,  not  being 
diseased,  stands  out  prominently.  There  is  usually  neither  pain 
nor  tenderness.  Rarely  slight  tenderness  of  the  nerve- 
trunks  and  spots  of  anaesthesia  may  be  found.  The  disease 
may  remain  limited  to  the  musculo-spirals,  or  may  spread  to 
other  nerves,  causing  paralysis  of  other  muscles  of  the  arm, 
especially  the  biceps  and  deltoid.  The  leg  may  be  affected. 
The  deep  reflexes  are  absent. 

There  is  another  type,  not  so  common  as  the  above,  in 
which  atrophy  is  first  noticed  in  the  adductor  muscles  of  the 
thumb  and  intrinsic  muscles  of  the  hand  (lumbricals  and  in- 
terossei),  and  the  symptoms  resemble  in  their  progress  those 
of  progressive  muscular  atrophy  (p.  222).  In  these  cases 
there  is  involvement  of  the  ganglion-cells  in  the  anterior  horns 
of  the  cord. 

Arsenical  neuritis :  It  is  important  to  remember  that  arsenic 
given  in  medicinal  doses  has  caused  neuritis.  The  symptoms 
consist  of  paralysis  of  the  extensors  of  the  arms  and  legs ; 
muscular  atrophy ;  pains  of  a  shooting,  darting  character ; 
tenderness  over  the  nerve-trunks,  and  frequently  anaesthesia. 
Eruptions  and  pigmentation  of  the  skin  are  often  present. 

Diphtheritic  neuritis  :  The  paralysis  usually  makes  its  ap- 


102  DISEASES  OF  THE  PERIPHERAL  NERVES. 

pearance  during  convalescence,  but  may  occur  in  the  midst 
of  the  attack.  It  begins  in  the  muscles  of  the  palate,  evi- 
denced by  a  nasal  voice  and  difficulty  in  deglutition  and  re- 
gurgitation of  liquids  through  the  nose.  Inspection  shows 
the  palate  to  hang  lower  than  usual,  and  that  it  is  not 
elevated  when  the  patient  utters  the  sound  "  ah."  In  mild 
cases  the  paralysis  may  remain  confined  to  this  part.  More 
usually  it  extends  to  muscles  of  the  eyes,  especially  the 
ciliary,  evidenced  by  impaired  vision  and  loss  of  the  power 
of  accommodation.  The  arms  and  legs  may  then  become 
affected.  In  125  cases  analyzed  by  GoodalP  paralysis  of  the 
palate  was  noticed  first  in  83  ;  of  the  ciliary  muscles  in  20 ; 
of  the  palate  and  ciliary  muscles  in  6  ;  in  4,  of  the  palate  and 
lower  extremities  ;  in  3,  of  the  lower  extremities  ;  in  2,  of 
the  muscles  of  the  pharnyx  ;  and  of  the  muscles  of  respira- 
tion in  2.  In  the  remaining  6  cases  the  parts  first  affected 
were  scattered,  one  case  each,  over  various  other  parts  of  the 
body. 

When  the  limbs  are  affected  the  muscles  soon  become 
flaccid  and  atrophy,  and  the  reaction  of  degeneration  in 
various  degrees  is  found.  The  knee-jerk  is  absent — in  fact, 
it  may  be  absent  before  other  signs  of  paralysis  are  mani- 
fest. Sensory  disturbances  are  most  frequently  absent.  If 
present,  they  consist  of  numbness,  tinglings,  and  ansesthesia. 

The  heart's  action  is  often  rapid  and  irregular,  due  to  in- 
volvement of  the  pneumogastrics.  In  rare  instances  there  are 
incontinence  of  urine,  and  in  adults  loss  of  sexual  power. 

Beri-beri,  endemic  neuritis,  or  kak-ke,  is  probably  due  to  a  spe- 
cific micro-organism.  Diet  appears  to  have  considerable  in- 
fluence in  its  production.  Yorderman,  a  Dutch  physician,  has 
stated  that  those  who  eat  white  rice,  that  which  has  been  de- 
prived of  the  pericarp,  are  much  more  liable  to  suffer  than 
those  who  eat  the  red,  from  which  it  has  not  been  removed. 
It  is  infectious  and  contagious,  and  is  met  with  in  epidemics 
in  Japan,  China,  Philippine  Islands,  Ceylon,  parts  of  India, 
and  other  tropical  localities.  It  also  occurs  among  sailors  on 
ships  carrying  cargoes  of  sugar.    Intestinal  parasites  have  been 

1 "  Diphtheritic  Paralysis,"  E.  W.  Goodall,  M.  D.  Lond. ;  Brain, 
p.  282,  1895. 


MULTIPLE  NEURITIS. 


103 


found  to  be  very  prevalent  in  those  suffering  from  beri-beri. 
It  can  be  propagated  by  water. 

The  symptoms  are  the  usual  ones  of  multiple  neuritis — 
viz.,  pain ;  tenderness  ;  muscular  weakness  and  atrophy ; 
anaesthesia  in  varying  degrees,  associated  with  oedema ;  a 
tendency  to  effusion  into  serous  cavities  ;  cardiac  disturbance  ; 
and  general  malaise.  In  some  cases  the  oedema  and  serous 
effusion  are  absent,  and  these  cases  are  attended  with  exten- 
sive paralysis,  even  of  the  facial  muscles,  and  excessive  pain. 
In  others  the  pain,  tenderness,  and  atrophy  are  absent,  the 
symptoms  consisting  of  oedema,  weakness,  and  loss  of  knee- 
jerk  (moist  variety). 

The  pneumogastric,  phrenic,  and  cardiac  plexuses  of  nerves 
are  apt  to  be  affected,  when  death  ensues.  Degeneration  of 
the  peripheral  nerves  is  found  in  the  ordinary  cases,  while  in 
the  moist  cases  the  phrenic,  sympathetic,  and  vaso-motor 
nerves  only  are  involved. 

Other  forms  of  multiple  neuritis :  The  remaining  forms  re- 
semble in  their  general  features  those  just  described. 

Multiple  neuritis — diagnosis :  There  should  not  be  any  diffi- 
culty in  making  a  diagnosis  of  multiple  neuritis.  The  dis- 
eases most  likely  to  be  confounded  with  it  are  acute  polio- 
myelitis, acute  ascending  myelitis,  and  locomotor  ataxia.  The 
differences  between  it  and  poliomyelitis  are  well  shown  in 
the  following  modification  of  the  summary  by  Starr : 


Acute  poliomyelitis. 

Sudden  onset,  with  fever  and 
development  of  paralysis  in  all 
the  limbs,  followed  in  from  three 
to  five  days  by  subsidence  of  par- 
alysis, which  remains  in  a  few 
muscles  of  one  limb ;  or,  if  two 
are  affected,  the  paralysis  is  rarely 
symmetrical.  If  the  onset  is  sub- 
acute, four  weeks  are  the  duration 
of  onset.  The  muscles  are  not 
tender.  Sensory  symptoms  are 
rare,  and  when  present  soon  sub- 
side. 


Multiple  neuritis. 

Fatigue  for  some  weeks ;  then 
sudden  onset  and  progress  for  two 
weeks  with  or  without  fever.  Legs 
usually  first  affected,  then  arms, 
then  body.  The  paralysis  has  no 
tendency  to  subside  for  some  time 
(months).  The  limbs  are  affected 
symmetrically.  Usually  there  are 
tenderness  of  the  nerve-truuks  and 
affected  muscles,  and  pain,  with 
areas  of  anaesthesia. 


104         DISEASES  OF  THE  PERIPHERAL  NERVES. 

In  acute  myelitis  the  loss  of  sensation  is  complete,  and  be- 
gins at  a  well-marked  line  which  extends  around  the  body  at 
the  level  of  the  cord-lesion  and  involves  all  parts  below  it. 
A  girdle-pain  is  usually  present.  There  is  incontinence  of 
urine  and  faeces,  and  bedsores  develop.  There  is  no  tender- 
ness of  the  nerve-trunks. 

In  loGomotoi'  ataxia  there  are  no  muscular  or  nerve  tender- 
ness, muscular  weakness,  nor  atrophy,  and  the  Argyll-Robert- 
son pupil  can  usually  be  found. 

Idiopathic  multiple  neuritis  may  be  mistaken  for  Landry^s 
paralysis ;  in  this,  however,  there  are  but  slight,  if  any,  sen- 
sory symptoms,  and  no  changes  in  the  electrical  reactions. 

The  fact  that  the  neuritis  is  due  to  alcohol  can  be  deter- 
mined by  the  history  of  steady  indulgence,  although  in  women 
this  may  often  be  denied ;  by  the  intense  pain  and  muscular 
tenderness,  especially  of  the  calves ;  by  the  peculiar  distri- 
bution of  the  paralysis  (extensors  of  both  arms  and  legs) ; 
and  by  the  frequent  accompanying  mental  symptoms. 

That  lead  is  the  cause  can  be  recognized  by  finding  the  blue 
line  upon  the  gums,  often  a  history  of  preceding  lead-colic, 
and  exposure  to  the  poison  ;  the  absence  of  pain  and  tender- 
ness ;  and  the  paralysis  first  appearing  in  and  often  confined 
to  the  muscle  supplied  by  the  muscnlo-spirals,  excepting  the 
supinator  longus  and  extensor  ossis  metacarpi  pollicis. 

In  musculo-spiral  paralysis  from  other  causes  these  muscles 
do  not  escape,  and  the  trouble  will  be  most  likely  unilateral. 

Diphtheritic  neuritis  is  peculiar  in  the  frequent  absence  of 
sensory  symptoms,  the  muscles  of  the  throat  and  eye  being 
first  attacked.  When  the  muscles  of  the  extremities  are 
primarily  paralyzed  an  attack  of  poliomyelitis  might  be  sus- 
pected ;  but  the  previous  history  of  recent  diphtheria,  the 
symmetry  and  frequently  progressive  character  of  the  par- 
alysis, and  slighter  changes  in  the  electrical  reactions  which 
distinguish  the  neuritis,  are  not  characteristic  of  poliomyelitis 
(see  p.  207).  It  must  be  remembered  also  that  there  are  other 
forms  of  palsy  associated  with  diphtheria.  As  in  other  acute 
infectious  diseases,  sudden  hemiplegia  due  to  either  thrombo- 
sis, embolism,  or  hemorrhage  may  occur.  This  form  resembles 
cerebral  hemiplegia  from  other  causes  (see  Cerebral  Palsies 
of  Children).     Diphtheritic  paralysis  may  be  accompanied 


MULTIPLE  NEURITIS.  105 

by  a  rapid  and  complete  palsy  of  one  or  more  of  the  cranial 
nerves,  which  is  apt  to  be  permanent,  and  is  probably  due  to 
an  acute  inflammation  of  their  nuclei. 

In  cases  of  multiple  neuritis  which  do  not  conform  to  the 
types  above  described,  careful  investigation  must  be  made  for 
the  existence  of  any  of  the  rarer  causes  mentioned. 

Multiple  neuritis — prognosis  :  In  patients  previously  healthy 
and  in  whom  the  heart  or  respiratory  muscles  do  not  become 
paralyzed,  recovery  is  the  rule.  Before  this  is  complete, 
months  will  usually  elapse.  Some  muscles  may  never  en- 
tirely recover,  and  then  contractures  are  apt  to  result.  Sen- 
sory symptoms  always  disappear  first.  Idiopathic,  alcoholic, 
and  diphtheritic  neuritis  are  especially  liable  to  a  fatal  issue, 
owing  to  the  liability  to  involvement  of  the  nerves  supplying 
the  heart  and  respiratory  muscles. 

Multiple  neuritis — treatment :  When  possible  the  cause 
should  be  removed.  In  alcoholics  this  must  be  done  with 
caution,  large  doses  of  strychnine  and  other  heart-tonics  being 
substituted.  Absolute  rest  in  bed  is  essential,  excepting  in 
those  cases  due  to  lead,  in  which  the  arms  are  alone  affected. 
For  the  relief  of  pain  similar  measures  to  those  recommended 
for  local  neuritis  may  be  employed.  Owing  to  the  depressing 
effects  of  the  drugs  recommended  for  this  purpose,  salicylates 
and  others,  they  must  be  used  cautiously,  and  strychnine  or 
caffeine  are  advantageously  combined  with  them.  Morphine 
should  only  be  used  as  a  last  resort.  After  the  acute  symp- 
toms have  subsided,  measures  to  increase  the  nutrition  of  the 
muscles  are  indicated,  as  massage  ;  causing  muscular  contrac- 
tions by  electricity ;  and  tonics,  such  as  strychnine  in  large 
doses,  especially  indicated  in  the  alcoholic  form.  Cod-liver 
oil,  iron,  and  small  doses  of  bichloride  of  mercury  or  iodide 
of  potassium  may  also  be  useful  in  this  stage.  The  food  dur- 
ing the  acute  stage  should  be  easily  digested  and  nutritious. 
Care  should  be  taken  to  prevent  contractions  of  the  muscles. 
This  may  be  done  by  passive  movements  and  mechanical  ap- 
pliances. Thus  :  foot-drop  may  be  overcome  by  pads  exert- 
ing pressure  against  the  ball  of  the  foot.  If  there  is  much 
hypersesthesia,  measures  to  support  the  bed-clothing  must  1)6 
employed. 


CHAPTER  YII. 

DISEASES  OF  CEANIAL  NERVES. 

OLFACTORY  NERVES  AND  TRACT. 

The  functions  of  these  nerves  may  be  disturbed  by  dis- 
ease anywhere  in  their  course,  from  their  distribution  in  the 
nasal  mucous  membrane  to  their  centres  in  the  cerebral  cor- 
tex (imcinate  gyrus).  This  disturbance  may  be  manifested  in 
subjective  sensations  of  smell,  or  parosmia ;  increased  sensi- 
tiveness, or  hyperosmia ;  and  loss  of  the  sense  of  smell,  or 
anosmia. 

Parosmia  :  Hallucinations  of  smell  are  found  in  the  insane, 
in  whom  the  sensation  is  usually  unpleasant ;  in  epileptics,  in 
whom  sometimes  the  aura  may  be  represented  by  an  unpleas- 
ant odor ;  and  in  cases  of  tumor  situated  in  the  region  of  the 
cerebral  centres  for  smell.  Rarely,  after  head-injuries  the 
sense  is  perverted,  odors  of  different  character  appearing  alike 
or  the  odor  may  be  changed. 

Hyperosmia :  This  usually  occurs  in  nervous,  hysterical 
individuals. 

Anosmia  :  This  may  be  produced  by  :  (1)  Affections  of  the 
"  terminals "  of  the  nerves  in  the  nasal  mucous  membrane, 
with  diseases  of  which  it  is  commonly  associated.  This  is 
the  most  frequent  cause. 

(2)  Lesions  of  the  bulbs  or  tracts,  which  may  be  due  to 
falls  or  blows ;  caries  of  the  cranial  bones ;  meningitis  or 
tumor.  The  sense  of  smell  may  be  lost  in  locomotor  ataxia, 
probably  due  to  atrophy  of  the  nerves. 

(3)  Lesions  of  the  olfactory  centres.  In  some  cases  the 
loss  may  be  congenital,  owing  to  the  centres  not  being  de- 
veloped. 

Tests  for  the  sense  of  smell  have  been  described  on  p.  49. 

OPTIC  NERVE  AND  TRACT. 

The  visual  pathway  :  This  commences  in  the  rods  and  cones 
of  each  retina,  the  deepest  layer  of  which  gives  origin  to  the 

106 


P'iG.  27. 


1^4 


t^t^™! 


r^^^PYe^g. 


The  visual  tract.  The  result  of  a  lesion  anywhere  between  the  chiasm  and  the  cu- 
neus  is  to  produce  homonymous  hemianopsia.  H,  lesion  at  chiasm  causing 
bilateral  temporal  hemianopsia  ;  N,  lesion  at  chiasm  causing  unilateral  nasal 
hemianopsia;  T,  lesion  at  chiasm  causing  unilateral  temporal  hemianopsia; 
SN,  substantial  niga  of  crus;  L,  lemniscus  in  crus ;  RN,  red  nucleus;  111,  third 
nerves. 

lor 


108  DISEASES  OF  CRANIAL  NERVES. 

optic  nerves.  These  pass  to  the  chiasm,  where  partial  decussa- 
tion occurs,  and  each  optic  tract  as  it  leaves  the  chiasm  con- 
tains fibres  "  originating  "  in  the  retina  of  each  eye.  Each 
nerve  therefore  contains  three  fasciculi  :  (1)  a  bundle  of  direct 
fibres  which  comes  from  the  external  or  temporal  third  of 
each  retina  and  passes  into  the  optic  tract  of  the  same  side  ; 
(2)  a  bundle  of  fibres  which  comes  from  the  internal  or  nasal 
two-thirds  of  the  retina,  and  at  the  chiasm  passes  into  the 
optic  tract  of  the  opposite  side ;  (3)  a  bundle  of  fibres  which 
proceeds  from  the  macular  region  and,  decussating,  passes 
partly  to  the  optic  tract  of  the  same  side  and  partly  to  that 
of  the  opposite  side  (Fig.  27).  After  leaving  the  chiasm 
each  tract  passes  backward,  winding  around  the  cerebral  crus, 
and  most  of  the  fibres  end  in  the  anterior  quadrigeminal 
body,  the  geniculate  bodies,  and  the  posterior  part  of  the 
optic  thalamus,  or  pulvinar.  These  constitute  the  primary 
optic  centres,  and  are  concerned  in  the  movements  of  the  eye 
and  reflex  movements  of  the  iris  and  ciliary  body.  From 
these  centres  fibres  arise  which  pass  through  the  posterior 
part  of  the  internal  capsule,  and,  as  the  radiations  of  Gra- 
tiolet,  pass  to  the  region  about  the  calcarine  fissure  in  the 
occipital  lobe.  The  angular  gyrus  is  also  connected  with  this 
region.  In  the  calcarine  region  (primary  cortical  centre)  of 
each  side  are  represented  the  temporal  third  of  the  retina  of 
the  same  side  and  the  nasal  two-thirds  of  the  opposite  side. 
Each  angular  gyrus  (higher  or  secondary  cortical  centre) 
is,  according  to  Ferrier,^  in  relation  with  the  macula  of  the 
opposite  side.  It  has  its  highest  development  upon  the  left 
side. 

Functional  Disturbances  of  Vision. 

Toxic  amaurosis  may  occur  in  uraemia  and  in  poisoning  by 
lead,  alcohol,  and  rarely  quinine. 

Hysterical  amaurosis  :  Complete  loss  of  sight  in  one  or  both 
eyes  may  occur  in  hysteria.  Amblyopia,  however,  is  the 
more  frequent  condition  (see  Hysteria). 

Tobacco-amblyopia  is  caused  by  the  excessive  use  of  tobacco. 
The   loss  of  sight  is  gradual  and  equal  in  both  eyes.     The 

^  Wilfred  Harris  contends  that  the  cortical  centre  for  the  macular  region 
is  in  the  cuneus.     Brain,  p.  360,  1897. 


OPTIC  NEURITIS.  109 

centre  of  the  field  of  vision  is  particularly  affected.  Central 
scotoma  (blind  spots)  are  found  for  red  and  green.  Changes 
in  the  fundus  are  frequently  absent.  A  chronic  neuritis  of 
the  orbital  part  of  the  optic  nerve  (retrobulbar  neuritis)  may 
develop.  If  the  use  of  tobacco  is  persisted  in,  atrophy  may 
occur. 

Retinal  hypersesthesia  is  sometimes  seen  in  hysterical  indi- 
viduals. 

Optic  Neuritis. 

Neuritis  of  the  optic  nerve  occurs  in  two  forms  :  first,  in 
which  there  are  distinct  lesions  at  the  intra-ocular  end  of  the 
nerve  (intra-ocular  optic  neuritis)  ;  and,  second,  those  cases 
which  are  unassociated  with  such  lesions  (orbital  optic  neur- 
itis or  retrobulbar  neuritis). 

The^rs^  is  the  only  form  which  concerns  the  neurologist. 
It  is  also  known  as  papillitis.  When  there  is  great  engorge- 
ment of  the  end  of  the  nerve,  so  that  it  projects  into  the 
interior  of  the  eye,  the  condition  is  spoken  of  as  choked  disc. 

Etiology :  The  mechanism  of  the  development  of  papillitis 
is  not  well  understood.  The  most  probable  explanation  is 
that  it  is  an  inflammatory  condition  due  to  irritation  of  the 
nerve  by  infection  of  the  subarachnoid  by  products  from  an 
intracranial  lesion  ;  or  by  the  action  of  toxic  substances  cir- 
culating in  the  blood. 

The  most  common  intracranial  cause  is  tumor  of  the  brain. 
"  Choked  <iiso"  is  the  usual  form  produced  by  this  cause. 
Meningitis,  especially  of  the  base,  and  abscess  of  the  brain 
may  also  cause  it.  Rare  causes  are  cerebral  hemorrhage ; 
thrombosis  of  the  cavernous  sinuses ;  chronic  hydrocephalus 
(unassociated  with  tumor) ;  aneurism  of  the  internal  carotid  ; 
myelitis ;  paretic  dementia  ;  chronic  insanity ;  epilepsy,  and 
multiple  sclerosis. 

Non -intracranial  causes  are  acute  infectious  diseases  ;  syph- 
ilis ;  lead  ;  alcohol ;  ursemia  ;  ansemia  ;  menstrual  disorders  ; 
exposure  to  cold  ;  rheumatism  ;  injuries  ;  disease  of  the  orbi- 
tal region  ;  and  possibly  intranasal  lesions.  Rarely  it  is 
congenital.     Refractive  errors  also  produce  slight  grades. 

Optic  neuritis — symptoms  ;  There  is  increased  redness  of  the 


110  DISEASES  OF  CRANIAL  NERVES 

nerve-head,  the  edges  of  which  are  hazy ;  the  veins  and  ar- 
teries are  tinged,  especially  the  former.  In  severe  forms 
flame-shaped  hemorrhages  may  be  seen.  The  surface  is 
more  or  less  elevated.  In  addition  to  these  appearances,  if 
choked  disc  exists,  the  nerve-head  is  pushed  forward  into  the 
interior  of  the  eye,  and  the  retinal  vessels  may  be  hidden  in 
places.  Vision  may  be  unaffected  until  late  in  the  disease. 
Occasionally  it  is  lost  rapidly. 

The  treatment  of  optic  neuritis  comes  within  the  province 
of  the  ophthalmologist.  When  due  to  intracranial  causes 
the  ultimate  result  depends  whether  the  cause  can  be  relieved 
or  not. 

Optic  Atrophy. 

Etiology  :  This  may  be  primary,  most  of  the  cases  of  which 
are  associated  with  disease  of  the  spinal  cord,  notably  loco- 
motor ataxia ;  paretic  dementia  ;  and  disseminated  sclerosis. 
There  is  also  a  hereditary  forui  (see  Amaurotic  Family 
Idiocy)  at  about  the  age  of  puberty.  Cold,  infectious  dis- 
eases, sexual  excess,  diabetes,  alcohol,  and  lead  have  also 
been  assigned  as  causes  of  this  form. 

There  is  also  secondary  atrophy,  which  results  from  a  press- 
ure more  or  less  directly  applied  to  the  optic  nerve,  chiasm, 
or  tracts. 

Consecutive  atrophy  follows  neuritis. 

Optic  atrophy — symptoms :  These  are  loss  of  sight,  indi- 
cated by  diminished  acuity  of  vision,  diminution  of  the 
visual  field,  and  altered  perception  of  color. 

In  primary  atrophy  the  disc  has  a  gray  tint.  In  secondary 
atrophy  it  is  white  in  color. 

Hemnianopsia. 

A  lesion  in  the  chiasm,  tract,  or  centres  produces  hemian- 
opsia. 

This  is  divided  into  horizontal  when  the  dividing-line  is 
horizontal ;  and  vertical  when  the  dividing-line  is  vertical. 

Horizontal  hemianopsia  can  be  caused  by  a  lesion  so  situ- 
ated as  to  press  upon  the  upper  or  lower  part  of  the  chiasm ; 
downward  upon  one  optic  tract ;  or  upon  the  upper  or  lower 
part  of  both  optic  nerves. 


HEMIANOPSIA. 


Ill 


180 


180 


Bitemporal  hemianopsia  from  a  case  of  akromegaly  originally  under  the  care  of 
H.  C.  Wood  and  later  studied  by  F.  A.  Packard.  Eyes  examined  in  1885  by 
de  Schweinitz,  and  above  fields  found. 


112  DISEASES  OF  CRANIAL  NERVES. 

Vertical  hemianopsia :  This  is  subdividsd  into  several 
varieties  : 

Bitemporal  hemianopsia  (Fig.  28),  in  which  both  temporal 
fields  are  wanting,  can  only  be  caused  by  a  lesion  involving 
the  crossing  fibres  of  both  optic  tracts  in  the  middle  of  the 
chiasm  (Fig.  27). 

Binasal  hemianopsia,  in  which  both  nasal  fields  are  wanting, 
is  rare.  A  lesion  to  produce  this  must  be  on  both  sides  of 
the  chiasm ;  or  two  lesions,  one  on  the  outer  side  of  each 
optic  nerve,  are  required. 

Homonymous  hemianopsia  is  that  in  which  the  corresponding 
half  of  the  visual  field  in  each  eye  is  wanting. 

If  both  right  halves  are  wanting,  it  is  called  a  right 
homonymous  lateral  hemianopsia  (Fig.  28«)  ;  if  both  left 
halves,  a  left  homonymous  lateral  hemianopsia.  The  loss  of 
function  is  always  in  the  opposite  side  of  the  retina  from  the 
blind  field.  Thus,  if  the  left  halves  of  the  fields  are  want- 
ing, the  nght  halves  of  the  retina  are  blind. 

This  form  of  hemianopsia  may  be  produced  by  a  lesion 
situated  in  the  visual  tract  posterior  to  the  chiasm — i.  e.,  in 
the  occipital  lobe  involving  the  cortical  centres  of  vision ;  in 
the  optic  radiations,  internal  capsule — primary  optic  centres 
or  optic  tract  (Fig.  27).  The  lesion  is  on  the  opposite 
side  to  the  blind  fields.  It  is  either  in  the  tract  or  in  the 
primary  optic  centres — consequently  interfering  with  the  re- 
flex arc  of  the  pupil — if  Wernicke's  symptom,  known  as 
Wernicke's  hemiopic  pupillary  inaction  sign,  is  present.  This 
is  determined  as  follows : 

If  an  intense  beam  of  light  is  made  to  fall  upon  the  blind 
side  of  the  retina  and  causes  no  contraction  of  the  pupil,  it 
is  assumed  that  the  lesion  is  in  the  reflex  arc — /.  e.,  tract  or 
primary  centres.  If  there  is  a  contraction  of  the  pupil  when 
the  light  strikes  either  the  sound  or  the  blind  side,  the  lesion 
is  further  on  in  the  visual  pathway — i.  e.,  in  the  internal  cap- 
sule, radiations,  or  centre.  Considerable  skill  is  required  to 
make  this  observation. 

Homonymous  hemianopsia  is  the  most  common  form.  It 
may  be  complete,  the  entire  half  field  being  wanting ;  or  in- 
complete.    It  may  be  absolute — that  is,  all  three  functions  of 


HOMONYMOUS  HEMIANOPSIA. 


113 


sight — viz.,  perception  of  light,  of  form,  and  of  color,  are 
wanting;  or  it  maybe  relative — that  is,  light-sense  is  preserved 
and  one  or  both  of  the  other  forms  are  wanting  in  the  deficient 
area  of  the  field. 

Fig.  28a. 


Left  eye. 


90° 

Right  eye. 
Right  homonymous  hemianopsia,  from  a  patient  under  the  care  of  Wharton  Sinkler. 

Relative  hemianopsia  is  always  due  to  a  cortical  lesion  ;  but 
cortical  lesions  may  produce  the  absolute  form.     In  cortical 

8— N.  D. 


114  DISEASES  OF  CRANIAL  NERVES. 

lesions  there  is  usually  contraction  of  the  preserved  half-field, 
the  contraction  being  more  marked  in  that  of  the  eye  opposite 
the  lesion.  More  rarely  this  may  be  due  to  a  lesion  of  the 
tract.  Homonymous  hemianopsia  may  be  due  to  functional 
causes,  and  occurs  infrequently  in  hysteria  and  migraine.  In 
such  cases  it  is  usually  transient.  An  organic  lesion  near  the 
visual  tract  may  also  cause  a  transient  hemianopsia. 

MOTOR  NERVES  OF  THE  EYEBALL. 

The  motor  nerves  of  the  eyeball  are  the  third,  or  oculo- 
motor ;  the  fourth,  or  pathetic ;  and  the  sixth,  or  abducens. 
These  nerves  may  be  diseased  separately  or  collectively. 

The  Third  Nerve. 

Anatomy :  The  nucleus  of  origin  of  the  third  nerve  con- 
sists of  a  number  of  distinct  nests  of  cells,  each  of  which 
is  the  nucleus  which  furnishes  the  nerve-fibres  for  a  certain 
muscle.  The  arrangement  of  these  cells  and  the  muscles  they 
supply  are,  from  before  backward :  Sphincter  iridis ;  Ciliary 
muscle  ;  convergence-centre  ;  Rectus  superior ;  Rectus  inter- 
nus  ;  Levator  palpebrse  superioris  ;  Obliquus  inferior ;  Rectus 
inferior.  These  are  situated  along  the  floor  of  the  aqueduct 
of  Sylvius.  From  there  the  nerve  passes  through  the  cms, 
at  the  side  of  which  it  emerges.  After  passing  along  the 
cavernous  sinus  it  enters  the  orbit  through  the  sphenoidal 
fissure  and  supplies  by  its  superior  branch  the  levator  pal- 
pebrse  superioris  and  superior  rectus  ;  by  its  inferior  branch, 
the  inferior  oblique  and  internal  and  inferior  recti  muscles. 

Other  branches  supply  the  ciliary  muscle  and  constrictor 
of  the  iris.  Motor  fibres  from  the  nucleus  of  the  third  also 
run  out  through  the  seventh  nerve  and  supply  the  orbicularis 
palpebrarum  (Fig.  286). 

Paralysis  of  the  muscles  supplied  hy  the  third  nerve — eti- 
ology: A  common  cause  is  neuritis.  This  may  be  due  to 
some  infectious  disease,  as  diphtheria ;  to  traumatism,  and 
possibly  may  be  a  symptom  of  locomotor  ataxia.  An  aneu- 
rism, tumor,  or  meningitis  may  be  so  situated  as  to  involve 
alone  the  nerve-trunk. 

It    may  be    due    also  to    a    degeneration  of  the    nucleus, 


PARALYSIS  OF  THE  MUSCLES. 


115 


and  consequently  of  the  nerve-trunk.  This  is  almost  inva- 
riably associated  with  locomotor  ataxia,  paretic  dementia,  or 
syphilis.  Ptosis  has  been  produced  by  a  cortical  lesion  situ- 
ated in  or  near  the  angular  gyrus.  A  paralytic  ptosis  has 
also  been  seen  in  hysteria,  but  this  is  rare. 

Paralysis  of  the  muscles  supplied  by  the  third  nerve — symp- 
toms :  In  total  third  nerve  paralysis  the  upper  lid  hangs  down 

Fig.  286. 


Sagittal  section  through  the  cerebral  axis,  to  show  the  nuclei  of  the  ocular  nerves 
in  the  floor  of  the  aqueduct  of  Sylvius  and  the  fourth  ventricle,  and  the  course 
of  the  nerves  to  their  exit.  The  various  groups  of  cells  from  which  the  third 
nerve  arises  are  seen.  BjV,  red  nucleus  of  tegmentum  ;  L,  lemniscus  (sensory 
tract) ;  CC,  motor  tract  in  the  crus  cerebri  seen  to  traverse  the  pons  and  enter 
the  anterior  pyramid  of  the  medulla  (Starr). 

almost  or  completely  covering  the  eyeball  (ptosis).  On  open- 
ing the  eyelids  with  the  fingers  the  eye  is  noticed  to  be  turned 
outward  and  slightly  downward  (action  of  external  rectus  and 
superior  oblique),  and  the  pupil  is  dilated  and  responds  to 
neither  light  nor  accommodation.  The  eye  may  project 
slightly,  owing  to  the  weakness  of  most  of  the  muscles  which 
retain  it  in  place.  There  is  no  loss  of  sensation  in  the  con- 
junctiva. Cases  are  recorded  in  which  the  paralysis  was 
limited  to  the  extra-ocular  muscles,  the  iris  and  ciliary  mus- 
cle esca])ing.  Such  cases  are  probably  due  either  to  a  lesion 
situated  at  the  beginning  of  the  peripheral  course  of  the  nerve, 


116  DISEASES  OF  CRANIAL  NERVES. 

just  before  all  the  fibres  have  converged  into  one  trunk,  the 
ciliary  and  pupillary  fibres  being  there  nearer  the  middle  line  ; 
or  to  a  lesion  attacking  the  branches  of  the  trunk  within  the 
orbit,  after  they  have  divided  to  go  to  the  various  muscles. 

Owing  to  similar  situations  of  the  lesion,  there  may  be 
paralysis  limited  to  a  single  extra-ocular  muscle.  That  of 
the  internal  rectus  is  the  most  common.  When  the  muscle  of 
one  side  is  aifected  the  patient  holds  his  head  downward  and 
toward  the  paralyzed  side. 

Isolated  paralysis  of  the  levator  palpebrce  superioris,  causing 
ptosis,  may  be  due,  in  addition  to  a  lesion  involving  the 
branches  as  above  mentioned,  to  a  disease  of  the  nucleus,  or 
to  a  lesion  situated  in  the  tract  of  the  third  nerve  between 
the  nucleus  and  its  cortical  centre.  It,  however,  is  often  the 
first  symptom  of  a  later  more  complete  third  nerve  palsy,  in 
some  instances  preceding  for  weeks  the  involvement  of  the 
other  muscles.  Isolated  paralysis  of  the  inferior  oblique  is 
exceedingly  uncommon. 

The  paralysis  may  be  limited  to  the  Infra-ocular  muscles. 
If  complete,  there  would  be  dilatation  and  immobility  of 
the  pupil  (iridoplegia)  to  both  light  and  accommodation ; 
when  there  is  loss  of  response  to  liglit  only,  it  is  called  reflex 
iridoplegia ;  when  there  is  loss  of  the  power  of  accommoda- 
tion only,  it  is  termed  cycloplegia.  Either  one  of  these  func- 
tions may  be  aflFected  without  the  other.  The  lesion  is 
usually  a  nuclear  degeneration.  Reflex  iridoplegia  (Argyll- 
Robertson  pupil)  is  most  frequently  seen  in  locomotor  ataxia 
and  paretic  dementia.  Total  iridoplegia  is  most  often  seen  in 
cerebral  syphilis.  Either  may  be  the  permanent  symptom 
of  a  former  more  extensive  third  nerve  palsy.  A  bilateral 
paralysis  of  the  third  nerve  is  most  frequently  syphilitic. 

Recurrent  form  :  This  affection,  also  known  as  oj)hthalmo- 
plegic  migraine,  is  rare.  It  most  frequently  attacks  females. 
It  usually  begins  early  in  life.  The  symptoms  are  unilateral 
headache,  lassitude,  nausea,  slight  fever,  and  complete  paral- 
ysis of  the  third  nerve  on  the  same  side  as  the  pain.  Other 
cranial  nerves  (fifth,  sixth,  and  seventh)  may  be  involved. 
The  attacks  come  periodically  and  last  from  several  days  to 
long  periods  of  time.  In  some  cases  one  or  more  of  the 
muscles  do  not  recover,  but  remain  permanently  paralyzed. 


THE  SIXTH  NERVE.  117 

The  pathology  is  uncertain.  Basal  meningitis  appears  to 
have  been  the  cause  in  some  instances. 

The  Fourth  Nerve. 

Anatomy :  The  fourth  nerve  originates  from  a  nucleus  at 
the  level  of  the  depression  midway  between  the  anterior  and 
posterior  corpora  quadrigemina.  It  lies  near  the  middle 
line  in  front  of  the  gray  matter  which  surrounds  the  aque- 
duct of  Sylvius,  in  a  hollow  on  the  dorsal  side  of  the  poste- 
rior longitudinal  fasciculus ;  and  is  separated  by  a  very 
slight  interval  from  the  lower  end  of  the  third  nucleus 
(Bruce)  (Figs.  286  and  28c).  Most  of  the  fibres  after  leaving 
the  nucleus  decussate  in  the  valve  of  Vieussens.  The  external 
origin  of  the  nerve  is  from  the  upper  surface  of  this  valve, 
whence  it  passes  around  the  crus  to  the  anterior  edge  of  the 
pons.  From  there  it  passes  through  the  cavernous  sinus, 
enters  the  orbit  through  the  sphenoidal  fissure  and  supplies 
the  superior  oblique  muscle. 

Paralysis  of  the  muscle  supplied  by  the  fourth  nerve — 
Symptoms :  Isolated  paralysis  of  the  superior  oblique  muscle 
is  most  rare.  When  present  the  eye  is  rotated  upward  and 
inward.  Diplopia  and  secondary  deviation  occur.  Marked 
vertigo  is  also  a  frequent  symptom. 

Involvement  of  the  nerve-trunk  or  its  nucleus  due  to 
causes  similar  to  those  producing  paralysis  of  the  third 
nerve  are  the  etiological  factors. 

The  Sixth  Nerve. 

Anatomy :  The  sixth  nerve  arises  from  a  nucleus  in  the 
floor  of  the  fourth  ventricle  (Fig.  28  c).  It  is  bordered  upon 
its  inferior,  upper,  and  inner  sides  by  the  root  of  the  facial 
nerve.  Its  superficial  origin  is  between  the  pons  and  me- 
dulla, external  to  the  pyramids.  It  enters  the  wall  of  the 
cavernous  sinus,  passes  through  the  sphenoidal  fissure  to  the 
orbit,  and  supplies  the  external  rectus  muscle.  Its  nucleus  is 
connected  with  those  of  the  third  and  fourth  nerves  by  the 
posterior  longitudinal  fasciculus.  Fibres  from  the  sixth 
nucleus  also  pass  through  the  fasciculus  to  the  nuclei  of  the 


118 


DISEASES  OF  CRANIAL  NERVES. 


third  nerve  (that  of  the  internal  rectus  muscle)  on  the  oppo- 
site side.  Through  this  the  sixth  nucleus  governs  conjugate 
deviation  of  the  eyes — i.  e.,  when  the  internal  rectus  of  the 
right  eye  and  the  external  of  the  left  cause  both  eyes  to  look 
to  the  left  side,  or  vice  versa. 


Fig.  28c. 


E.R, 


OVIN 


a,  diagram  showing  the  arrangement  of  the  nuclei  of  the  motor  nerves  of  the  eye, 

and  the  decussation  of  the  fourth  and  internal  rectus  branch  of  the  third  nerve. 

b,  diagram  showing  the  probable  relations  of  the  nuclei  of  the  sixth  and  of  the 

internal  rectus  branch  of  the  third  to  the  brain.    P.  L.  B.,  posterior  longitu- 
dinal bundle. 


The  cortical  centres  of  these  muscles  are  not  definitely 
known.  The  fibres  from  them  pass  through  the  internal  cap- 
sule, those  of  the  third  at  the  "  knee,"  before  reacliing  the 
nuclei.  Most  of  those  which  pass  to  the  third  and  sixth 
nuclei  decussate,  and  terminate  in  the  nuclei  of  the  opposite 
side.  As  has  already  been  said,  the  fibres  of  the  fourth 
nerve  do  not  decussate  until  after  they  have  left  the  nucleus 
to  pass  to  the  periphery. 

Paralysis  of  the  muscles  supplied  by  the  sixth  nerve — symp- 
toms and  etiology :  Paralysis  of  tlie  external  rectus  muscles 
causes  a  convergent  strabismus  with  diplopia.  Vertigo  may 
be  a  symptom.     It  is  due  to  disease  either  of  the  nerve-trunk 


ACUTE   OPHTHALMOPLEGIA.  119 

or  its  nucleus,  the  causes  of  which  are  similar  to  those  pro- 
ducing interference  with  the  functions  of  the  third  and  fourth 
nerves.  It  is  at  times  an  early  symptom  of  locomotor  ataxia. 
In  old  age  transient  forms  of  unknown  origin  have  been  ob- 
served.    There  is  also  a  double  palsy  which  is  congenital. 

Combined  paralysis  of  the  ocular  muscles — etiology :  Paraly- 
sis of  the  third,  fourth,  and  sixth  nerves  may  be  caused  by  a 
lesion  of  the  cortex,  nuclei,  or  nerve-trunks.  It  is  most 
commonly  due  to  a  gross  lesion  at  the  base  of  the  brain, 
meningitis,  most  frequently  syphilitic  or  tubercular,  or  tumor. 
Commonly  in  such  cases  other  cranial  nerves  are  also  involved. 
While  paralysis  of  any  ocular  muscle  due  to  any  cause  is  an 
ophthalmoplegia,  the  term  is  more  commonly  applied  when 
due  to  nuclear  disease.     This  may  be  acute  or  chronic. 

Acute  Ophthalmoplegia. 

Etiology  :  It  may  be  caused  by  a  hemorrhage  into  the  region 
of  the  nuclei ;  an  embolus  or  thrombus  in  a  branch  of  the 
basilar  artery  ;  or  an  acute  hemorrhagic  polio-encephalitis  in- 
volving the  nuclei  (polio-encephalitis  superior  of  Wernicke). 
The  causes  of  the  latter  are  the  infectious  febrile  diseases, 
especially  influenza ;  tuberculosis ;  possibly  syphilis ;  alcohol ; 
ptomains  from  decayed  fish  and  meat ;  lead  ;  rarely  trauma- 
tism. 

Symptoms :  When  due  to  hemorrhage  there  would  be  a 
sudden  paralysis  of  the  ocular  muscles,  preceded  probably  by 
vomiting  and  convulsions.  When  an  acute  hemorrhagic 
polio-encephalitis  is  the  lesion  there  may  be  prodromes,  such 
as  general  malaise,  headache,  vertigo,  and  vomiting.  The 
temperature  may  be  either  slightly  elevated,  subnormal,  or 
remain  normal.  Soon  there  is  rapidly  developing  paralysis 
of  the  ocular  muscles,  excepting  the  levator  palpebrse  supe- 
rioris  and  sphincter  of  the  iris,  which  often  escape.  Head- 
ache and  vertigo  continue,  and  soon  stupor  and  in  severe 
cases  coma  occur.  Acute  ophthalmoplegia  is  always  bilateral, 
and  may  be  associated  with  poliomyelitis,  and  with  paralysis 
of  muscles  of  the  face,  tongue,  and  palate,  due  to  involve- 
ment of  their  nuclei. 

Acute  ophthalmoplegia — diagnosis  and  prognosis :  The  pres- 


120  DISEASES  OF  CRANIAL  NERVES. 

ence  of  convulsions,  muscular  twitchings,  headache,  stupor, 
or  coma  would  distinguish  the  aflFection  from  neuritis.  The 
disease  is  often  fatal,  the  most  favorable  cases  being  those 
which  follow  the  infectious  diseases.  In  cases  which  recover 
paralysis  may  remain  (chronic  ophthalmoplegia). 

Treatment,  that  of  acute  hemorrhagic  encephalitis  (see  p. 
266). 

Chronic  Ophthalmoplegia. 

Etiology  :  Chronic  ophthalmoplegia,  or  chronic  nuclear  ocu- 
lar paralysis,  may  occur  as,  (1)  one  of  the  terminations  of 
the  acute,  the  lesions  of  which  have  produced  degenerative 
changes ;  (2)  a  chronic  degeneration  of  the  nuclei  (chronic 
polio-encephalitis  superior)  which  may  be  due  to  syphilis, 
diphtheria,  diabetes,  or  be  in  association  with  or  preceding  the 
development  of  tabes  ;  paresis  ;  disseminated  sclerosis  ;  pro- 
gressive muscular  atrophy ;  chronic  bulbar  palsy  (chronic 
polio-encephalitis  inferior) ;  (3)  a  congenital  and  sometimes 
hereditary  affection.  The  lesion  is  a  degeneration  of  the 
nuclei  similar  to  that  occurring  in  chronic  poliomyelitis. 

Chronic  ophthalmoplegia — symptoms  :  The  aifection  is  char- 
acterized by  a  gradual  and  progressive  paralysis  of  many  or 
all  of  the  ocular  muscles.  Often  one  of  the  first  symptoms 
complained  of  is  diplopia,  which  may  be  transient.  The 
other  muscles  then  become  involved,  often  in  an  irregular  man- 
ner without  reference  to  their  functions.  Ptosis  may  be  either 
absent  or  is  incomplete.  The  paralysis  may  progress  until  a 
certain  development  is  reached  and  then  remain  stationary ; 
or  it  may  continue  until  all  of  the  muscles  are  involved. 
Both  eyes  are  usually  affected,  but  it  may  be  unilateral. 
Diplopia  is  apt  to  disappear  in  the  later  stages.  In  some 
cases  the  intra-ocular  muscles  escape  (ophthalmoplegia  ex- 
terna) ;  in  others  they  are  the  only  ones  to  become  affected 
(ophthalmoplegia  interna). 

Diagnosis  :  The  distinction  must  be  made  between  paralysis 
due  to  nuclear  disease,  peripheral  neuritis,  disease  at  the 
base  of  the  brain,  and  intracerebral  disease.  This  at  times 
may  be  difficult.  From  neuritis,  nuclear  disease  differs  in 
the  absence  or  slight  development  of  ptosis,  the  bilateral  dis- 
tribution of  the  symptoms,  and  the  association  of  the  palsy 


PARALYSIS  OF  MUSCLES  OF  THE  EYE.  121 

with  symptoms  of  degenerative  cerebral  or  spinal  disease. 
The  exemption  of  the  iutra-ocular  muscles,  when  present,  is 
in  favor  of  nuclear  disease  ;  but  it  may  occur  in  neuritis.  In 
disease  at  the  base,  headache,  nausea,  vertigo,  and  optic  neu- 
ritis would  probably  be  present.  From  the  close  proximity 
of  their  trunks  at  the  base  of  the  brain  the  fifth  nerve  would 
probably  suffer  with  the  sixth,  and  other  cranial  nerves  would 
be  apt  to  be  irregularly  involved. 

A  lesion  of  the  cms  cerebri  would  probably  cause  paralysis 
of  the  third  nerve,  which  would  be  associated  with  hemiple- 
gia of  the  opposite  side.  Lesions  in  the  region  of  the  corpora 
quadrigemina  may  also  cause  paralysis  of  the  third  nerve, 
owing  to  the  closeness  of  its  nuclei  to  these  structures.  Such 
paralysis  would  be  accoiiipanied  by  incoordination  of  move- 
ment, possibly  forced  movements.  If  the  lesion  is  a  tumor, 
general  symptoms  common  to  cerebral  growths  occur. 

Ptosis  may  be  produced  by  disease  of  the  sympathetic, 
causing  paralysis  of  the  smooth  muscular  fibres  in  the  fascia 
of  the  orbit  (fibres  of  Miiller).  In  these  cases,  whicli  are 
uncommon,  the  ptosis  is  incomplete,  and  there  would  be  con- 
traction of  the  pupil  upon  the  diseased  side. 

Paralysis  of  muscles  of  the  eye — prognosis :  If  the  primary 
cause,  such  as  syphilis  or  rheumatism,  can  be  influenced  by 
treatment,  the  prognosis  is  good  ;  but  it  must  be  remembered 
that  even  when  due  to  these,  permanent  damage  may  have 
been  done  to  the  nuclei  or  nerve-fibres,  when  permanent 
paralysis  would  result.  When  a  symptom  or  forerunner  of 
degenerative  disease  of  other  portions  of  the  nervous  system 
(tabes,  etc.),  the  possibility  of  which  should  always  be  re- 
membered, the  prognosis  is  not  good,  although  sometimes 
the  paralysis  may  disappear. 

Treatment  consists  of  the  use  of  potassium  iodide  and  mer- 
cury in  large  doses  when  syphilis  is  a  cause,  and  even  when 
no  history  of  such  can  be  obtained,  it  is  well  to  give  these 
drugs  a  thorough  trial ;  salicylates,  if  any  history  of  rheuma- 
tism. Tonics  such  as  strychnine,  arsenic,  and  small  doses  of 
bichloride  of  mercury,  may  be  tried.  A  weak  (1  m.  amp.) 
constant  galvanic  current,  the  positive  pole  at  the  nape  of 
the  neck  and  the  negative  over  the  affected  eye,  is  also  useful. 
When  it  exists  as  a  complication  of   some  other  disease  treat- 


122  DISEASES  OF  CRANIAL  NERVES. 

ment  for  that  disease  should  be  employed.  Diplopia  may  be 
corrected  by  employment  of  prisms,  or  by  placing  a  ground 
glass  over  one  eye. 

Spasms  of  the  Ocular  Muscles. 

Etiology  and  symptoms :  These  may  be  tonic  or  clonic  ;  in 
origin,  functional  or  organic.  The  causes  of  functional  spasm 
are  hysteria,  neurasthenia,  and  refractive  errors.  Tonic 
spasm  of  the  orbicularis  palpebrarum  occurring  in  hysteria 
may  simulate  ptosis.  A  convergent  strabismus  may  also  be 
due  to  hysterical  spasm  of  the  internal  recti.  Other  symp- 
toms of  hysteria  would,  of  course,  accompany  these  condi- 
tions.    Refractive  errors  are  a  common  cause  of  ciliary  spasm. 

Spasm  of  organic  origin  is  due  to  irritation  in  the  course 
of  the  ocular  nerves  between  the  cortex  and  muscle.  Conju- 
gate deviation  is  the  common  manifestation  of  this  spasm. 
This  may  be  caused  by  irritation  of  any  part  of  the  cortex, 
but  most  markedly  so  when  the  irritation  is  in  the  occipital 
lobe.  Lesions  in  the  region  of  the  internal  capsule  also 
cause  it.  In  spasmodic  conjugate  deviation  in  these  situa- 
tions the  eyes  look  away  from  the  side  of  the  lesion ;  in  the 
paralytic  form  caused  by  a  destructive  lesion  the  opposite  is 
the  case.  Lesions  in  the  pons  also  may  produce  this  symp- 
tom ;  but  here  irritative  lesions  (spasm)  being  on  the  same 
side  as  the  sixth  nerve  nucleus  cause  the  eyes  to  deviate 
toward  the  side  of  the  lesion  ;  while  destructive  lesions  (para- 
lytic) cause  the  opposite  eifect. 

Nystagmus  is  characterized  by  rapid  involuntary  move- 
ments of  the  eyeball,  usually  from  side  to  side,  but  some- 
times in  a  vertical  or  rotary  direction.  In  most  cases  it  is 
bilateral.  It  may  be  congenital.  It  occurs  in  some  eye  dis- 
eases and  in  certain  occupations.  It  is  a  common  symptom 
of  disseminated  sclerosis  and  Friedreich's  ataxia.  It  may 
accompany  various  forms  of  paralytic  and  spasmodic  disorder 
of  ocular  movements,  due  either  to  disease  of  the  nuclei  or 
of  the  commissural  and  association  tracts  which  connect 
these  nuclei  and  various  parts  of  the  brain  together.  It  has 
also  occurred  in  conjunction  with  ear  diseases. 


PARALYSIS  OF  THE  FIFTH  NERVE.  123 

THE  FIFTH  NERVE. 

Anatomy  :  The  fifth,  or  trigeminal,  nerve  consists  of  two 
portions,  a  motor  and  a  sensory.  The  central  neuron  for  the 
motor  portion  arises  in  the  lower  extremities  of  the  central 
convolutions,  near  those  for  the  lips  and  tongue.  It  passes 
from  there  downward,  through  the  knee  of  the  capsule,  and 
after  decussating  joins  the  motor  nucleus  in  the  medulla. 
Fibres  from  this  nucleus  form  the  motor  root,  which  eventu- 
ally becomes  part  of  the  inferior  maxillary  division. 

The  sensory  portion  arises  in  the  cells  of  the  Gasserian 
ganglion,^  the  cells  of  which  give  off  a  long  dendrite,  from 
which  the  axon  originates.  The  former  goes  to  the  periph- 
ery, forming  the  three  divisions,  ophthalmic,  superior  maxil- 
lary, and  inferior  maxillary,  of  the  sensory  portion  of  the 
nerve. 

The  axons  enter  the  pons,  where  they  divide :  one  divi- 
sion (the  ascending  root)  passes  upward  almost  to  the  third 
nerve  nucleus.  They  terminate  in  free  ramifications  in  the 
substantia  gelatinosa.  The  other  and  largest  division  (de- 
scending root)  passes  downward  into  the  cord  about  as  far  as 
the  second  cervical  segment.  These  fibres  end  about  cells  in 
the  substantia  gelatinosa.  From  these,  fibres  arise  which 
enter  the  fillet,  decussate,  and  ascend  to  the  brain-cortex  (cen- 
tral convolutions?).  Collaterals  from  the  descending  root 
pass  to  the  nuclei  of  the  motor  cranial  nerves.  Its  many 
connections  explain  the  liability  of  the  nerve  to  reflex  irrita- 
tions. 

The  sensory  divisions  supply  the  skin  of  the  face  and  head 
as  far  back  as  the  occiput ;  and  the  conjunctiva  and  mucous 
membrane  of  the  mouth,  tongue  (the  anterior  part  of  which 
also  receives  fibres  of  taste),  upper  part  of  pharynx,  teeth, 
salivary  and  lachrymal  glands  (Fig.  29).  The  motor  por- 
tion supplies  the  tensor  tympani  and  muscles  of  mastication — 
i.  e.,  masseters,  pterygoids,  temporals,  buccinator,  mylo-hyoid 
and  anterior  bulb  of  the  digastric. 

Paralysis  of  the  fifth  nerve — etiology :  Either  the  motor  or 
the  sensory  root,  or  one  of  the  divisions  of  the  latter,  owing 

'  The  Gasserian  ganglion  is  analogous  to  the  ganglion  upon  the  posterior 
roots  of  the  spinal  nerves. 


124  DISEASES  OF  CRANIAL  NERVES. 

to  the  difference  of  their  course,  may  be  affected  or  the  entire 
nerve  may  be  involved.  A  lesion  situated  at  the  base  of  the 
brain  involving  the  superficial  origin  would  cause  a  general 
paralysis,  while  a  disease  of  the  inferior  maxillary  division 
would  cause  motor  and  sensory  symptoms,  the  latter  being 
limited  to  the  peripheral  distribution  of  that  branch. 

The  chief  cmises  of  paralysis  of  the  nerve  are  as  follows  : 

(a)  The' ophthalmic  division  lies  in  the  cavernous  sinus, 
where  it  may  be  damaged  by  tumors  in  the  pituitary  region, 
and  within  the  orbit  it  may  be  injured  by  new  growths  and 
inflammatory  processes.  The  superior  and  inferior  maxillary 
divisions  lie  in  the  spheno-maxillary  fossa,  where  they  are 
liable  to  suffer  from  wounds  and  tumors  which  may  invade 
this  region. 

(b)  At  the  base  of  the  brain  the  nerve  may  suffer  from 
tumors,  meningitis  (especially  syphilitic),  and  caries  of  the 
temporal  bone. 

(c)  Disease  in  the  pons,  as  tumor,  hemorrhage,  or  soften- 
ing, or  a  patch  of  sclerosis  (in  disseminated  sclerosis),  may 
damage  the  sensory  nucleus  (descending  root).  As  a  rule, 
owing  to  its  great  extent,  damage  to  this  nucleus  causes  only 
partial  paralysis. 

(d)  Traumatism  to  the  mouth  and  nose  may  injure  some 
branches  of  the  nerve. 

(e)  Neuritis  may  occur  in  syphilitic,  gouty,  or  rheumatic 
individuals,  or  from  exposure,  but  is  rare. 

Symptoms :  Paralysis  of  the  sensory  division  causes  loss  of 
sensation  in  the  parts,  both  skin  and  mucus  membranes,  sup- 
plied by  the  nerve.  The  loss  may  affect  the  entire  region 
when  the  disease  is  at  the  root,  or  if  all  three  branches  are 
diseased ;  but  if  only  one  branch  is  diseased,  the  loss  is 
limited  to  the  part  supplied  by  it  (Fig.  29).  Pain-sense  is 
usually  lost  before  the  tactile. 

Neuralgic  pain  in  the  course  of  the  nerve  often  precedes 
the  development  of  the  anesthesia.  Loss  of  taste  on  one  side 
of  the  tongue  and  palate  usually  results.  When  this  symp- 
tom is  not  present  the  damage  to  the  nerve  is  but  partial  or 
the  lesion  is  within  the  pons.  If  the  loss  is  confined  to  the 
anterior  two-thirds,  the  lesion  is  in  the  lingual  branch  between 
its  peripheral  distribution  and  where  it  joins  the  chorda  tym- 


PARALYSIS  OF  THE  FIFTH  NERVE. 


125 


pani.  Various  trophic  and  vaso-motor  symptoms  may  also 
result.  Increase  of  the  salivary  and  lachrymal  secretions 
may  occur  if  there  is  irritation ;  but  when  destruction  has 
occurred,  diminution.  Paleness  of  the  face  upon  the  affected 
side  may  be  observed.  The  cornea  often  becomes  dry  and 
opaque,  and  ulceration  and  eventually  destruction  of  the  eye- 

FiG.  29. 


Cutaneous  sensory  areas  of  the  trigeminal  nerve.  I,  first  or  ophthalmic  division ; 
//,  second  or  superior  maxillary  division ;  III,  inferior  maxillary  division ;  C, 
anterior  division  of  the  second  cervical  nerve,  which  supplies  chiefly  the  front 
and  side  of  the  neck.  The  small  occipital  nerve  (occipitalis  minor,  occipitalis 
parvus,  occipitalis  extermis,  occipitalis  anterior),  vsrhich  supplies  the  skinbehind 
the  ear  and  the  area  directed  in  a  pointed  shape  toward  the  crown  of  the  head, 
is  not  indicated  by  shading  or  lettering-.  O,  great  occipital  nerve  (occipitalis 
major,  occipitalis  magnus,  occipitalis  maximus,  occipitalis  internus),  represent- 
ing the  posterior  branch  of  the  second  cervical  nerve,  which  supplies  the  skin 
corresponding  with  the  upper  part  of  the  occipital  bone  and  adjoining  part  of 
the  scalp,  as  shown  by  the  shading  which  extends  toward  the  vertex.  A  branch 
of  the  posterior  division  of  the  third  cervical  nerve  also  ramifies  in  the  skin 
above  the  occipital  protuberance,  and  the  pneumogastric  has  an  auricular 
branch  which  appears  cutaneously  behind  the  ear. 

ball  may  result.  Ocular  changes  are  especially  frequent  in 
disease  of  the  Gasserian  ganglion  or  of  the  nerve  anterior  to 
it.  Herpes,  most  often  in  the  superior  maxillar  distribution, 
may  be  a  symptom.  In  hemiatrophy  of  the  face  degenera- 
tion of  the  ascending  root  has  been  found. 


126  DISEASES  OF  CRANIAL  NERVES. 

The  symptoms  of  disease  of  the  motor  portion  are  weak- 
ness or  paralysis  of  the  muscles  of  mastication  upon  the 
side  of  the  lesion.  Weakness  of  the  masseter  and  temporal 
muscles  is  made  evident  by  placing  the  finger  over  the  muscles 
and  causing  the  patient  to  bring  the  teeth  together,  when 
weakness  or  absence  of  contraction  becomes  evident.  In 
pterygoid  paralysis  the  jaw  can  be  moved  toward,  but  not 
away  from,  the  paralyzed  side  ;  and  when  depressed  the  jaw 
deviates  to  the  paralyzed  side.  Atrophy  of  the  muscles  may 
cause  sinking  in  the  temporal  and  zygomatic  fossse. 

Diagnosis  :  Complete  paralysis,  both  motor  and  sensory,  of 
the  fifth  nerve,  does  not  resemble  any  other  condition.  In 
hemiansesthesia  there  is  angesthesia  of  the  face  in  the  distri- 
bution of  the  fifth  nerve  ;  but  there  is  also  loss  of  sensibility 
in  the  back  of  the  head  and  of  the  trunk  and  limbs  of  one 
side,  and  often  there  is  hemianopsia.  When  there  is  pain  the 
condition  might  be  confounded  with  neuralgia,  but  the  exist- 
ence of  anaesthesia  and  the  loss  of  taste  would  render  plain 
the  nature  of  the  affection.  The  diagnosis  of  the  locality  of 
the  lesion  is  important,  and  dei)ends  upon  the  distribution  of 
the  anaesthesia  and  the  accompanying  symptoms. 

Paralysis  of  the  entire  nerve,  motor  and  sensory,  is  most 
probably  due  to  disease  at  the  base  of  the  brain  or  of  the 
Gasserian  ganglion.  If  there  is  also  paralysis  of  the  sixth 
nerve,  the  lesion  would  involve  the  lateral  surface  of  the  pons. 
When  the  superior  maxillary  is  alone  affected,  especially  if 
there  coexists  paralysis  of  the  motor  nerves  of  the  eyeball,  the 
lesion  is  probably  at  the  sphenoidal  fissure  or  in  the  orbit ; 
paralysis  limited  to  the  distribution  of  the  inferior  maxillary 
points,  to  a  lesion  in  the  superior  maxillary  bone  or  spheno- 
maxillary fissure.  Paralysis  of  the  superior  and  inferior 
maxillary  nerves  is  probably  due  to  disease  in  or  about  the 
spheno-maxillary  fissure. 

Crossed  paralysis  of  the  fifth  nerve  is  due  to  a  lesion  in  the 
lower  half  of  the  pons  or  upper  part  of  the  medulla.  Con- 
jugate deviation  of  the  eyes  to  the  side  of  the  lesion  associated 
with  fifth  nerve  paralysis  is  always  due  to  a  lesion  in  the  pons. 

Treatment :  Our  success  in  treating  paralysis  of  the  fifth 
nerve,  and  consecjuently  the  prognosis,  depends  upon  the 
cause.     If  it  cannot  bo  removed,  nothing  can  be  done.     Anti- 


NEURALGIA    OF  THE  FIFTH  NERVE.  127 

syphilitic  treatment  sliould  be  tried.  The  application  of  heat 
is  useful  in  cases  due  to  exposure  to  cold  and  consequent  neu- 
ritis. Counterirritation  over  the  mastoid  is  also  useful.  For 
the  relief  of  pain,  in  addition  to  heat,  phenacetin,  antipyrin, 
and  similar  remedies  may  be  tried.  The  anaesthesia,  if  the 
nerve  has  not  been  entirely  destroyed,  is  often  benefited  by 
the  frequent  application  of  a  rapidly  interrupted  faradic  cur- 
rent applied  through  the  wire  brush.  The  eye  should  be  kept 
thoroughly  and  frequently  cleansed  with  boric  acid  solution. 
In  the  intervals  it  is  well  to  keep  it  covered  with  a  watch- 
crystal  held  in  place  by  adhesive  strips. 

Neuralgia  of  the  fifth  nerve — etiology :  The  causes  of  neu- 
ralgia are  stated  on  p.  85.  There  is  a  special  form  of  neu- 
ralgia of  the  fifth  nervCj  known  as  tic  douloureux  or  proso- 
palgia, which  comes  on  at  the  degenerative  period  of  life, 
after  forty. 

Symptoms:  The  pain  of  neuralgia  of  the  fifth  nerve  re- 
sembles in  character  that  of  neuralgia  elsewhere  (p.  85).  It 
is  also  usually  unilateral,  deep  seated,  and  corresponds  to  the 
distribution  of  the  division  or  branch  aifected.  It  more  com- 
monly affects  one  or  two  divisions  of  the  nerve  than  all  three. 
During  the  paroxysms  the  pain  is  more  intense  at  certain 
points,  which  are  tender ;  and  if  the  attack  is  of  long  dura- 
tion, the  tenderness  remains  between  the  paroxysms. 

Neuralgia  of  the  ophthalmic  division  is  most  usually  con- 
fined to  the  supra-orbital  branch,  sometimes  termed  "brow 
ague,"  owing  to  the  fact  that  it,  more  frequently  than  other 
forms,  is  due  to  malaria.  The  pain  radiates  over  the  front 
of  the  head  from  the  supra-orbital  notch,  and  may  also  be  felt 
in  the  eyelid,  in  the  eyeball,  and  high  up  on  the  side  of  the 
nose.  A  tender  point  usually  exists  at  or  near  the  supra- 
orbital notch.  More  rarely  the  tender  points  may  be  found 
on  the  upper  eyelid  and  at  the  junction  of  the  nasal  bone 
with  the  cartilage.  Ocular  neuralgia,  pain  referred  to  the 
eyeball,  is  also  a  common  form.  The  pain  may  be  spontane- 
ous, but  is  often  excited  by  the  use  of  the  eyes,  and  may  be 
accompanied  by  dimness  of  vision  and  lachrymation.  The 
pain  feels  as  if  it  were  deep  in  the  orbit  and  is  of  a  tearing 
character;  it  is  sometimes  bilateral.  Those  who  have  had 
rheumatic  iritis  are  especially  liable. 


128  DISEASES  OF  CRANIAL  NERVES. 

In  neuralgia  of  the  superior  maxillary  division  the  pain  is 
felt  in  the  face  between  the  orbit  and  the  mouth,  in  the  side 
of  the  nose,  and  upper  teeth.  Tender  points  are  found  at 
the  infra-orbital  foramen,  along  the  gum  of  the  upper  jaw, 
at  the  side  of  the  nose,  and  over  the  prominent  part  of  the 
malar  bone. 

When  the  inferior  maxillary  division  is  affected  the  pain 
may  be  felt  just  in  front  of  the  ear;  in  the  posterior  part  of 
the  temple ;  at  the  emergence  of  the  nerve  from  the  inferior 
dental  foramen;  just  above  the  parietal  eminence,  and  at  the 
side  of  the  tongue.  The  pain  may  be  confined  to  one  of  these 
regions  or  may  be  diffused,  involving  all  of  these  points. 
]Movements  of  the  jaw  or  tongue  are  liable  to  aggravate  the 
paroxysms  in  this  form. 

The  pain  may  at  times  extend  to  other  branches  than  the 
one  aifected  or  to  other  nerves.  In  very  severe  neuralgia 
there  may  occur  reflex  twitchings  of  the  facial  muscles  dur- 
ing the  paroxysms.  There  may  be  vaso-motor  disturbances, 
as  congestion,  flushings,  sweating.  Trophic  symptoms,  espe- 
cially herpes,  may  also  occur. 

Tic  douloureux  occurs  after  forty,  is  chronic  in  its  course, 
and  is  especially  apt  to  aifect  the  superior  maxillary  division, 
but  may  aifect  two  or  all ;  is  characterized  by  most  agonizing 
pain,  which  occurs  suddenly  and  frequently,  but  is  of  short 
duration,  and  is  usually  accompanied  by  facial  spasm.  The 
morbid  anatomy  of  neuralgia  is  discussed  on  p.  85. 

Diagnosis :  The  points  by  which  we  would  diagnose  neu- 
ralgia from  neuritis  and  headache,  with  which  it  would  be 
most  liable  to  be  confounded,  have  been  mentioned  on  p.  86. 
Having  determined  that  the  condition  does  exist,  it  is  essen- 
tial to  determine  the  cause  if  possible. 

Prognosis :  When  there  is  a  cause  that  can  be  removed, 
such  as  anaemia  or  debility,  the  prognosis  is  good.  In 
cases  due  to  any  cause  of  long  duration  the  possibility  of 
degenerative  changes  occurring  in  the  nerve  must  be  con- 
sidered. The  longer  the  duration  the  worse  the  prognosis. 
The  forms  occurring  after  middle  life  are  exceedingly  intract- 
able. Neuralgia,  no  matter  how  severe,  does  not  apparently 
shorten  Yifv. 

Neuralgia  of  the  fifth  nerve — treatment :    This  consists  of 


NEURALGIA    OF  THE  FIFTH  NERVE.  129 

measures  for  the  relief  of  pain  and  for  the  removal  of  the 
cause.  The  salicylates  are  most  useful  when  the  trouble  is 
rheumatic,  and  may  be  tried  in  any  case.  They  must  be 
given  in  full  doses  (gr.  x-xv,  four  times  daily).  Antipyrin, 
phenacetin,  and  similar  remedies  are  most  useful,  but  must 
be  used  with  caution,  remembering  their  depressing  action 
upon  the  heart.  In  neurotic  individuals  small  doses  of  the 
bromides  may  give  relief.  Nitroglycerin  (gr.  j^^^,  every  three 
hours)  is  useful,  especially  in  neuralgias  of  the  aged.  Al- 
cohol, valerian,  or  compound  spirit  of  ether  may  abort  an 
attack.  Atropine  hypodermatically  is  effective  in  some  cases. 
One  of  the  most  valuable  remedies  is  aconitia,  which  may  be 
given  in  doses  commencing  wdth  gr.  ^^o^  and  gradually  in- 
creasing by  gr.  2^  each  time,  when  necessary,  until  the 
physiological  action  of  the  drug  is  produced.  This  drug  in 
a  large  number  of  cases  is  curative,  and  its  use,  if  watched, 
may  be  continued  a  long  time.  In  supra-orbital  neuralgia, 
or  in  fact  in  any  periodic  neuralgia,  large  doses  of  quinine 
are  often  beneficial.  Ergot  in  full  doses  has  also  been  recom- 
mended for  this  form. 

The  local  application  of  dry  heat,  of  liniments  composed 
of  equal  parts  of  chloral  and  camphor,  or  of  menthol  (gr. 
xx-lj),  may  give  relief.  A  valuable  means  of  affording  re- 
lief is  the  use  of  electricity.  It  is  best  applied  by  placing 
the  cathode  at  some  indiff'erent  point  and  placing  the  anode 
over  the  painful  points  in  turn.  The  current  should  be 
constant,  of  moderate  strength,  which  should  be  decreased 
gradually,  and  applied  daily  or  oftener  if  possible.  The 
placing  of  a  20  per  cent,  solution  of  cocaine  upon  the  elec- 
trode increases  its  effect  (cataphoresis). 

To  remove  the  cause  all  sources  of  reflex  irritation  must 
be  sought  for :  carious  teeth  removed  or  put  in  good  condi- 
tion ;  catarrh  of  the  nose  or  throat  treated,  and  the  digestive 
organs  carefully  looked  after.  The  excessive  use  of  tea, 
coffee,  alcohol,  tobacco,  or  sexual  indulgence  must  be  pro- 
hibited, and  the  patient  put  under  as  good  hygienic  condi- 
tions as  ])ossible.  A  removal  to  a  warm,  equable  climate  may 
bring  relief.  For  chroriic  cases  Dana  has  recently  advocated 
a  plan  of  treatment  which  often  ])i'()ves  successful  :  The 
patient  is  put  to  bed,  given  liquid  diet,  and  once  each  day 
9— N.  D. 


130  DISEASES  OF  CRANIAL  NEBVES. 

given  a  hypodermatic  injection  of  strychnine,  beginning  with 
gr.  yV  ^"^^  gradnally  increasing  until  a  dose  of  ^-^  gr.  if 
possible  is  reached.  It  takes  about  three  weeks  to  do  this. 
The  dose  is  then  gradually  decreased  until  the  original  dose 
is  reached.  This  entire  process  takes  about  six  weeks,  and 
should  be  repeated  if  the  pain  does  not  entirely  disappear  or 
a  relapse  occurs.  During  this  time  iron  and  iodide  of  potas- 
sium, or  other  appropriate  drugs,  may  also  be  given. 

When  all  else  fails  resection  of  the  nerve  or  removal  of 
the  ganglion  must  be  considered.  In  severe  cases,  if  relief 
is  not  secured,  it  is  not  well  to  wait  too  long  before  advo- 
cating surgical  measures,  for  fear  that  degenerative  changes 
may  advance  beyond  the  ganglion  into  the  nuclei,  when,  of 
course,  nothing  can  be  done. 

THE  SEVENTH  NERVE. 

Anatomy :  The  central  neurons  of  the  facial  nerve  arise 
from  the  cells  of  the  lower  extremities  of  the  central  convolu- 
tions (Fig.  44).  Fibres  from  these  form  a  tract  which  passes 
through  the  corona  radiata,  the  anterior  portion  of  the  poste- 
rior limb  of  the  capsule,  to  the  tegmentum,  when  they  decus- 
sate and  enter  the  nucleus  of  the  opposite  side.  This  is  sit- 
uated at  the  lower  part  of  the  pons,  in  a  line  with  the  motor 
nuclei  of  the  iifth  and  ninth  and  tenth  nerves  (nucleus  am- 
biguus).  To  its  outer  side  is  the  descending  root  of  the  fifth 
nerve.  From  the  nucleus  the  fibres  take  a  circuitous  course, 
bending  to  form  a  V,  in  the  bottom  of  which  lies  the  nucleus 
of  the  sixth  nerve.  They  emerge  to  form  the  facial  nerve 
from  the  lower  border  of  the  pons,  between  the  reflex  ex- 
tremity of  the  olive  and  the  restiform  body.  The  eiglith  or 
auditory  nerve  is  separated  but  very  slightly  from  it.  The 
nerve  maybe  subdivided  into  three  portions:  (l)an  intra- 
cranial portion,  which  extends  from  the  superficial  origin  to 
where  it  enters  the  internal  auditory  meatus  ;  (2)  an  intra- 
osseous portion,  which  begins  at  the  internal  auditory  meatus 
and  runs  through  the  Fallopian  canal  to  the  styk>-mastoi(l 
foramen;  and  (3)  an  extracranial  portion,  or  all  that  part  of 
the  nerve  external  to  the  stvlo-mastoid  foramen.  Within  the 
Fallopian   canal,  at   what   is   known   as   the  "knee"   of  the 


PARALYSIS   OF  THE  SEVENTH  NERVE.  131 

facial,  is  the  geniculate  ganglion.  From  this  arise  two 
nerves,  the  intermediary  nerve  of  Wrisberg  and  the  chorda 
tympani. 

The  chorda  tympani,  through  which  sensations  of  taste  are 
transmitted,  runs  through  the  canal  in  company  with  the 
seventh  nerve  and  finally  joins  the  lingual  branch  of  the  fifth 
to  be  distributed  to  the  tongue  (see  p.  137). 

Through  the  posterior  longitudinal  fasciculus  the  seventh 
nerve  probably  receives  fibres  from  the  oculomotor  nucleus, 
which  supply  the  orbicularis  palpebrarum.  This  accounts  for 
the  escape  of  that  muscle  in  central  palsies.  It  probably  re- 
ceives fibres  from  the  hypoglossal  nucleus  which  supply  the 
orbicularis  oris  and  some  fibres  from  the  fifth.  The  seventh 
nerve  supplies  all  the  muscles  of  the  face,  eyelids,  and  month, 
excepting  those  supplied  by  the  third  and  fifth  nerves ;  the 
occipito-frontalis,  platysma,  the  muscles  of  the  eyebrows,  the 
extrinsic  muscles  of  the  ear  and  of  the  nose. 

Paralysis  of  the  seventh  nerve — etiology :  Paralysis  of  the 
facial  nerve  may  be  due  to  lesions  of  either  the  central  or 
peripheral  neuron.  If  of  the  former,  it  may  be  either  corti- 
cal or  subcortical,  in  or  near  the  internal  capsule,  or  in  the 
pons.  If  of  tlie  latter,  it  may  be  either  nuclear  or  of  the 
nerve-trunk.  The  nerve  itself  may  be  involved  in  one  of 
three  situations — viz.,  at  the  base,  or  intracranial  portion ; 
within  the  Fallopian  canal,  or  intra-osseous  portion ;  or  ex- 
ternal to  the  stylo-mastoid  foramen,  or  extracranial  portion. 

Central  palsies  are  due  to  a  vascular  lesion  ;  to  tumor  or 
abscess,  or  patch  of  sclerosis.  Nuclear  lesions  are  usually 
due  to  a  degeneration,  being  usually  a  part  of  the  so-called 
glosso-labio-laryngeal  paralysis ;  and  may  also  accompany 
other  degenerative  diseases,  as  progressive  muscular  atrophy, 
amyotrophic  lateral  sclerosis,  or  locomotor  ataxia.  If  acute, 
they  may  l)e  due  either  to  the  toxins  of  infectious  disease,  to 
alcoholic  or  mineral  poison  (polio-encephalitis  inferior) ;  or  to 
hemorrhage.  The  intracranial  portion  is  usually  affected  by 
the  exudation  of  meningitis,  frequently  syphilitic  ;  by  tumor 
or  fracture  at  the  base.  The  most  common  cause  of  facial 
])aralysis  is  neuritis  involving  the  intra-osseous  or  extracranial 
portions,  which  may  be  due  to  exposure  to  cold,  traumatisni, 
or  extension  of  iuHaniination    from    nii«ldl<'  ear  disease.     A. 


132  DISEASES  OF  CRANIAL  NERVES. 

few  cases  have  been  reported  of  congenital  bilateral  facial 
paralysis.^ 

Paralysis  of  the  seventh  nerve — symptoms :  In  central 
paralysis  the  muscles  of  the  lower  part  of  the  face  only 
are  involved,  the  patient  can  close  his  eye  and  wrinkle  the 
forehead,  and  the  electrical  reactions  are  normal.  If  cortical 
or  capsular,  there  will  usually  be  more  or  less  weakness  of  the 
arm  and  leg  upon  the  same  side,  and  there  will  be  in  addition 
involvement  of  the  tongue,  and,  if  a  left-sided  lesion,  apha- 
sia. A  lesion  in  the  pons  above  the  nucleus  will  cause  paraly- 
sis of  the  face,  arm,  and  leg  upon  the  same  side,  which  will 
usually  be  accompanied  with  some  sensory  loss,  conjugate 
deviation,  and  weakness  of  the  ocular  muscles.  When  in 
the  lower  part  of  the  pons  the  nucleus  will  probably  be 
affected,  and  as  the  facial  fibres  have  decussated  there  will 
be  paralysis  of  the  face  upon  the  same  side  as  the  lesion  and 
of  the  arm  and  leg  of  the  opposite  side.  Paralysis  of  the 
sixth  and  conjugate  deviation  of  the  eyes  may  be  associated. 

Nuclear  paralysis  is  always  bilateral.  The  paralysis  in  the 
chronic  forms  at  first  is  not  complete,  the  orbicularis  palpe- 
brarum and  orbicularis  oris  often  escaping,  and  develops 
gradually.  It  is  accompanied  by  paralysis  of  other  nerves 
(ninth  or  tenth)  or  by  symjotoms  of  other  diseases  (see  Bulbar 
Palsy,  p.  210).  If  acute  and  due  to  vascular  lesion,  death 
soon  ensues ;  otherwise  there  will  be  a  history  of  previous 
infectious  disease  or  exposure  to  the  toxic  influences  of  al- 
cohol or  mineral  poisons  (polioencephalitis,  p.  211).  Nuclei  of 
other  nerves  will  probably  also  be  diseased.  In  disease  of 
the  nerve-trunk  known  as  Bell's  palsy  the  symptoms  are 
most  marked  and  complete  (Fig.  30).  The  eye  upon  the 
affected  side  can  be  closed  but  partially  or  not  at  all ;  the 
lines  of  the  face  are  smoothed  out,  especially  noticeable  in 
the  forehead,  and  if  the  patient  attempts  to  frown  this  side 
remains  motionless.  The  mouth  is  drawn  more  or  less  to 
the  sound  side,  and  if  an  attempt  is  made  to  smile  this  is 
exaggerated.  Food  collects  between  the  tongue  and  the 
cheek.  The  tears  often  run  over  the  cheek,  owing  to  the  ina- 
bility to  wink.  Sensibility  is  preserved  and  there  is  usually 
no  pain.     At  times,  owing  to  involvement  of  the  few  fifth 

^  ThomaH.     Jour.  Nerv.  and  Mental  Diseases,  vol.  xxv.  p.  571  (Aug.  1898). 


PARALYSIS   OF  THE  SEVL'STJI  NERVK  133 

nerve  fibres,  there  may  be  slight  [)ain  or  acliiiitr  ii»  (h(^  re- 
gion of  the  ear  and  mastoid  process.  If  due  to  lesion  of  the 
intracranial  portion,  the  eighth  nerve,  owing  to  its  proximity, 
is  always  involved,  causing  deafness  of  nerve  origin. 

The  paralysis  may  be  bilateral,  and  other  cranial  nerves 
are  also  likely  to  be  involved,  causing  headache,  optic  neur- 
itis, and  other  symptoms  of  meningitis  or  tremor. 

Fig.  30. 


Complete  facial  palsy.    Patient  unable  to  close  the  l.\  e  nf  the  affected  side. 


In  lesion  of  the  interosseous  part,  the  most  common  type 
of  facial  palsy,  in  addition  to  the  symptoms  described  above, 
there  is  loss  of  the  sense  of  taste  in  the  anterior  part  of 
the  tongue  upon  the  diseased  side  (for  method  of  testing 
sense  of  taste,  see  p.  49),  due  to  involvement  of  the  chorda 
tympani.  Disease  limited  to  the  extracranial  portion  causes 
paralysis  of  all  the  branches  of  the  nerve,  but  the  sense  of 
taste  is  preserved.  Contractures  may  eventually  occur  in 
the  paralyzed  muscles,  causing  drawing  of  the  corner  of  the 
mouth  to  the  paralyzed  side. 

The  diagnosis  must  be  made  as  to  whether  the  lesion  is 
central  (supranuclear),  nuclear,  or  in  the  nerve-trunk  (infra- 
nuclear).  The  differences  in  the  symptoms  due  to  lesions  in 
each  of  these  situations  have  been  detailed  in  the  description 
of  the  symptoms. 


134  DISEASES  OF  CRANIAL  NERVES. 

The  prognosis  in  central  lesions  depends  upon  the  nature 
of  the  lesion.  The  facial  paralysis  occurring  as  a  part  of 
hemiplegia  due  to  apoplexy  often  recovers.  In  nuclear 
lesions  the  prognosis  is  bad.  When  due  to  a  neuritis,  ex- 
cepting when  due  to  suppurating  middle  ear,  recovery  occurs 
in  most  cases.  A  knowledge  of  the  condition  of  the  elec- 
trical reactions  is  of  much  help  in  forming  a  prognosis. 
When  after  ten  days  there  is  only  a  quantitative  decrease  to 
galvanism  or  faradism  recovery  will  probably  occur  in  a  few 
weeks  or  a  month.  When  reactions  of  degeneration  are 
present  the  period  of  time  necessary  for  recovery  will  depend 
upon  the  rapidity  with  which  they  have  appeared  after  the 
onset  of  the  paralysis  and  the  completeness  of  their  develop- 
ment. When  the  reaction  develops  rapidly  and  is  complete 
the  case  is  apt  to  last  many  months.  The  patient  should  be 
warned  as  to  the  possibility  of  contractures  occurring,  but 
these  frequently  disappear  in  time. 

The  treatment  in  central  and  nuclear  paralysis  of  the 
seventh  nerve  is  that  of  the  lesion  causing  it.  When  due  to 
a  neuritis  the  cause,  if  possible,  should  be  removed.  Thus, 
if  due  to  middle-ear  disease  this  must  be  thoroughly  treated. 
When  the  onset  has  been  rapid  a  blister  should  be  placed 
over  the  mastoid  process.  This  should  be  followed  by  hot 
applications  over  the  nerve.  A  purge  should  be  given  and 
salicylic  acid  in  some  form  administered.  Electricity  in  the 
form  of  a  constant  galvanic  current  may  be  used  in  this 
stage.  In  the  course  of  a  week  iodide  of  potassium  should 
be  substituted  for  the  salicylates  and  the  galvanic  current 
used  to  cause  muscular  contraction.  The  applications  should 
be  daily  when  possible.  Strj'chnine  is  also  of  value  at  this 
stage.  If  contractures  develop,  the  constant  galvanic  cur- 
rent, the  anode  over  the  muscles,  and  massage  may  be  of  help. 

Spasm  of  the  muscles  supplied  by  the  seventh  nerve — syno- 
nyms :  Care  must  be  taken  not  to  confound  spasm  of  these 
muscles  with  those  supplied  by  the  fifth  and  motor  nerves  of 
the  eye.  Facial  spasm  has  various  synonyms,  as  painless 
tic  ;  histrionic  spasm  ;  mimic  spasm. 

Facial  spasm — etiology :  Irritative  lesions  of  any  sort,  as 
tumors,  abscess,  meningitis,  hemorrhages,  etc.,  situated  in  the 
course  of  the  seventh  nerve-neurons,  from  cortex  to  periph- 


FACIAL  SPASM.  135 

ery,  may  be  a  cause  of  such  spasm.  It  may  be  caused 
reflexly  by  trigeminal  irritation,  as  from  a  (lecayed  tooth. 
Blepharospasm,  or  spasm  of  the  orbicularis  ])alpebrarum, 
may  be  caused  by  eye-strain,  foreign  bodies  in  the  eye,  cor- 
neal ulcer,  and  other  irritations.  It  may  be  hysterical. 
General  ill-health,  anaemia,  worry,  fatigue,  cold,  exposure, 
and  })regnancy  appear  in  some  cases  to  be  exciting  causes. 
In  a  large  number  of  cases  no  cause  can  be  found.  Tonic 
spasm,  due  to  secondary  contracture,  sometimes  follows  Bell's 
palsy.  Facial  spasm  is  usually  met  with  after  middle  life, 
and  is  more  common  in  women  than  men. 

Facial  spasm — symptoms :  The  onset  is  usually  gradual, 
one  or  two  muscles,  generally  the  orbicularis  palpebrarum, 
being  first  involved.  From  this  the  spasm  spreads  until 
either  others  or  all  the  muscles  upon  one  side  of  the  face 
supplied  by  the  seventh  are  affected.  After  a  long  period  of 
time  the  spasm  may  become  bilateral,  although  from  the 
first  in  some  cases  twitchings  of  muscles  upon  the  other  side 
may  occur.  Those  that  habitually  act  together  are  the  cor- 
rugator  supercilii  and  orbiculares  of  the  eyelids.  The 
spasm  may  be  either  tonic  or  clonic,  or  both  may  be  com- 
bined. Clonic  blepharospasm  is  also  known  as  nictitating 
spasm.  Motion  or  excitement  will  aggravate  or  may  excite 
an  attack.  The  spasm  decreases  or  ceases  during  sleep.  It 
is  not  attended  with  pain,  but  there  may  be  a  feeling  of 
fatigue.  Electrical  irritability  of  the  nerve  may  be  in- 
creased. It  may  be  associated  with  spasm  of  the  neck-, 
shoulder-,  and  arm-muscles.  Excepting  in  those  cases  due 
to  irritating  organic  lesions  in  the  tract  of  the  seventh  nerve- 
neurons,  no  morbid  anatomy  or  pathology  is  known. 

Diagnosis  :  Facial  spasm  must  be  distinguished  from  habit- 
chorea.  In  this  the  affection  begins  in  childhood,  at  first 
can  be  controlled,  and  the  movements  consist  of  a  wrinkling 
of  the  forehead  or  twitching  of  the  mouth. 

Facial  spasm  is  also  one  of  the  symptoms  of  the  disease 
variously  known  as  tic  convulsif,  palmus,  or  Gilles  de  la  Tou- 
rette's  disease  (see  p.  331).  The  mental  symptoms  of  this  are 
sufficient  to  distinguish  it  from  simple  facial  spasm.  In  de- 
termining the  cause  the  following  facts  must  be  remembered  : 
The  spasm  following  Bell's  palsy  is  tonic,  and  there  will  be 


136  DISEASES  OF  CRANIAL  NERVES. 

a  history  of  preceding  paralysis.  If  it  is  hysterical,  it  will 
be  accompanied  by  other  symptoms  of  hysteria  (see  p.  348"). 
In  reflex  spasms  careful  search  will  show  the  cause  of  irri- 
tation. When  due  to  organic  lesion  other  symptoms  are 
likely  to  be  present  or  will  develop.  Thus,  a  facial  spasm 
may  be  the  first  symptom  of  a  cortical  or  subcortical  irrita- 
tion ( Jacksonian  epilepsy).  Paralysis  also  usually  coexists  or 
develops  later,  and  the  general  symptoms  of  such  lesions  will 
be  present.  When  these  causes  can  be  eliminated  the  trouble 
is  the  idiopathic  spasm  or  painless  tic. 

Facial  spasm — treatment :  This  is  unsatisfactory.  Sources 
of  reflex  irritation,  if  they  exist,  must  be  removed.  The 
general  health,  if  necessary,  must  be  improved.  Hypoder- 
matic injections  of  atropine  often  give  relief.  Gelsemium 
and  conium  in  ascending  doses  by  the  mouth  have  been 
much  used.  Hot  applications  or  counterirritation  over  the 
point  of  emergence  of  the  nerve  may  be  tried.  Weir 
Mitchell  has  advised  freezing  by  means  of  the  rhigolene  or 
chloride  of  ethyl  spray.  Electricity  in  the  form  of  a  con- 
stant galvanic  current,  the  anode  over  the  various  muscles 
and  in  front  of  the  ear,  with  the  cathode  at  some  remote 
point,  is  often  of  much  service. 

THE  EIGHTH  NERVE. 

Paralysis  of  those  fibres  which  come  from  the  cochlea 
causes  loss  of  hearing.  When  there  is  irritation  of  them  sub- 
jective sensations,  as  noises  of  various  sorts,  tinnitus,  etc., 
result.  Disease  of  those  fibres  which  come  from  the  semi- 
circular canals  causes  vertigo  (see  p.  89). 

The  auditory  nerve  tract  may  be  affected  by  middle  or 
internal  ear  disease ;  by  lesions,  as  meningitis,  syphilitic 
usually  ;  or  tumor  at  the  base  of  the  brain ;  and  by  degener- 
ation in  locomotor  ataxia  ;  and  by  lesions  involving  the  nuclei 
in  the  upper  part  of  the  medulla  ;  by  lesions  in  the  tegmentum 
of  the  crus  cerebri  (which  ^vould  cause  symptoms  on  the 
opposite  side) ;  in  the  posterior  corpora  quadrigemina  and  in- 
ternal geniculate  body ;  in  the  posterior  part  of  the  internal 
capsule  and  in  the  first  temporal  convolution  (if  on  the  left 
side,  word-deafness  results,  see  Aphasia). 


DISEASES  OF  THE  NINTH  NEIiVE.  137 

THE  NINTH  OR  GLOSSOPHARYNGEAL  NERVE. 

Anatomy  :  This  nerve  has  three  functions — motor,  common 
sensibility,  and  special  sensibility — viz.,  taste. 

The  inotor  functions  of  the  nerve  are  doubtful.  It  proba- 
bly supplies  the  upper  pharyngeal  muscles.  The  nerve  of 
common  sensibility  of  the  upper  part  of  the  pharynx  and  the 
tympanic  cavity  is  probably  the  ninth.  The  nuclei  and  cen- 
tres of  origin  of  these  portions  of  the  nerve  are  in  common 
with  those  of  the  tenth,  and  will  be  described  with  them. 
The  course  of  the  nerve-fibres  of  taste  is  somewhat  doubtful, 
but  it  is  probably  as  follows :  The  set  of  fibres  originates  in 
the  cells  of  the  geniculate  ganglion  situated  on  the  facial 
nerve.  The  processes  of  these  cells  divide,  one  division  run- 
ning peripherally,  forming  the  chorda  tympani  nerve ;  this 
joins  the  lingual  branch  of  the  fifth  and  supplies  the  anterior 
two-thirds  of  the  tongue.  The  other  division  runs  centrally 
as  the  intermediary  nerve  of  Wrisberg,  which  terminates  in 
the  sensory  nucleus  of  the  glosso-pharyngeal  nerve. 

The  fibres  which  supply  the  posterior  part  of  the  tongue, 
palatal  arches,  soft  palate,  and  epiglottis,  arise  from  the  cells 
of  the  petrous  and  jugular  ganglion,  which  are  situated  upon 
the  nerve  in  the  jugular  foramen,  as  other  sensory  nerves  do, 
by  a  division  of  the  process,  one  division  passing  peripherally 
to  the  structures  above  named,  and  the  other  to  the  sensory 
nucleus  in  the  medulla.  From  there  the  fibres,  after  decus- 
sating, enter  the  latter  fillet  and  pass  through  the  posterior 
part  of  the  internal  capsule.  The  cortical  termination  is 
probably  in  or  near  the  anterior  inferior  portion  of  the  tem- 
poral lobe. 

It  is  proper  to  state  that  many  neurologists  believe  that 
the  fifth  nerve  is  the  nerve  of  taste,  fibres  from  the  chorda 
tympani  being  by  them  believed  to  go  to  the  Gasserian  gan- 
glion by  way  of  the  great  superficial  petrosal  nerve. 

Diseases  of  the  ninth  nerve — etiology :  Owing  to  its  close 
relation  with  the  tenth  and  accessory  portion  of  the  eleventh 
nerves,  lesions  rarely  aflPect  the  ninth  nerve  alone.  It  may 
be  implicated  by  disease  within  the  medulla,  either  hemor- 
rhage, acute  softening,  or  degeneration  (acute  and  chronic 
bulbar  palsy) ;  by  involvement  of  the  nerve-trunk  at  the  base 


138  DISEASES  OF  CRANIAL  NERVES. 

of  tlie  brain  with  meningitis  or  new  growth  ;  or  by  lesion  of 
the  seventh  within  the  Fallopian  canal.  Lesions  of  the  pos- 
terior portion  of  the  posterior  limb  of  the  internal  capsnle 
have  caused  loss  of  taste  upon  the  opposite  side,  as  would 
also  a  lesion  of  the  cortical  centres. 

Symptoms  produced  by  disease  limited  to  this  nerve  would 
be  disordered  sense  of  taste  and  some  loss  of  the  power  of 
swallowing.  The  sense  may  be  less  acute  or  lost  (ageusia) ; 
more  acute  than  normal  (hypergensia) ;  or  perverted  (para- 
geusia). The  methods  used  to  ascertain  the  existence  of 
lessening  or  loss  of  the  sense  are  detailed  on  p.  49.  Loss  of 
the  sense  is  usually  unilateral,  and  is  more  marked  on  the 
anterior  portion  of  the  tongue.  In  hypergensia  sapid  sub- 
stances may  be  almost  painfully  appreciated.  When  para- 
geusia exists  sweets  may  be  perceived  as  soon,  or  substances 
may  be  enjoyed  that  under  normal  circumstances  would  be 
loathed,  and  vice  versa.  Parageusia  may  occur  as  an  epileptic 
aura.  Ageusia  and  parageusia  may  occur  as  hysterical  symp- 
toms. 

THE  TENTH  OR  PNEUMOGASTRIC  OR  VAGUS  NERVE. 

Anatomy :  The  nerve  has  both  motor  and  sensory  func- 
tions. The  cortical  motor  centres  that  govern  laryngeal  and 
pharyngeal  movements  are  situated  at  the  base  of  the  pre- 
central  convolution  (Fig.  44).  Fibres  from  these  pass  down- 
ward near  the  pyramidal  tract  (anterior  to  it  in  the  capsule) 
and  after  decussating  reach  the  nucleus  ambiguus.  This  is 
situated  in  the  medulla  between  the  substantia  gelatinosa  and 
the  posterior  accessory  olive,  just  above  the  nucleus  of  tlie 
facial  nerve.  Fibres  also  reach  another  nucleus  (the  so-called 
sensory)  situated  just  behind  the  hypoglossal  nucleus  and 
extending  upward  to  the  floor  of  the  fourth  ventricle.  The 
axis-cylinders  from  the  cells  composing  these  nuclei  form  the 
motor  portions  of  the  ninth  and  tenth  nerves.  The  external 
origin  is  from  the  side  of  the  medulla  anterior  to  the 
restiform  body.  Until  recently  it  was  thought  that  the  cells 
of  the  lower  part  of  the  nucleus  ambiguus  gave  origin  to  the 
accessory  fibres  of  the  eleventh  nerve.  These  fibres  were 
thought  to  become  the  recurrent  laryngeal  nerve,  which  sup- 


DISEASES  OE  THE   Th'NTIl  NERVE.  139 

plies  all  of  the  mnscles  of  the  hiryiix  excepting  tlie  erieo- 
thyroid.  Grabower'  has  recently  shf)\vn  that  it  is  most  prob- 
able that  such  is  not  the  case,  but  that  the  hiryngeal  muscles 
are  all  supplied  by  the  tenth.  The  tenth  nerve  supplies  the 
muscles  of  the  pharynx,  larynx,  :ind  the  branches  going  to 
the  heart,  lungs,  oesophagus,  and  abdomen  contain  motor 
fibres. 

The  sensory  fibres  probably  arise  from  two  ganglia,  named 
the  ganglion  of  the  root  or  superior  ganglion  and  ganglion  of 
the  trunk  or  inferior  ganglion,  which  are  situated  upon  its 
trunk,  the  former  within  the  jugular  foramen  and  the  latter 
lower  down  upon  the  trunk  of  the  nerve.  From  these, 
fibres  enter  the  medulla  anterior  to  the  restiform  body 
and  communicate  with  the  nucleus  common  to  both  nerves 
which  extends  downward  into  the  cervical  region  of  the  cord, 
and  is  known  by  various  names,  viz.,  the  descending  root, 
the  slender  fasciculus,  respiratory  fasciculus,  and  fasciculus 
rotund  us. 

The  tenth  nerve  has  numerous  connections  with  the  sym- 
pathetic system  and  also  with  the  ninth,  the  eleventh,  the 
twelfth,  and  first  two  cervical  nerves.  Besides  being  the 
motor  nerve  of  the  muscles  of  the  larynx  and  most  of  those 
of  the  pharynx,  it  is  the  sensory  nerve  of  the  larynx  and 
most  of  the  pharynx,  and  sends  sensory  fibres  to  the  viscera 
(liver,  kidneys,  lungs,  heart,  etc.).  It  also  contains  vaso- 
motor and  secretory  fibres. 

Diseases  of  the  tenth  nerve — etiology :  The  nucleus  may 
be  diseased  by  acute  vascular  lesions  or  by  degenerative  proc- 
esses. The  roots  of  the  so-called  peripheral  origin  may  be 
damaged  by  meningitis  or  new  growth,  rarely  from  aneurism 
of  the  vertebral  artery.  The  nerve-trunk  in  the  neck  may 
suifer  from  deep-seated  tumors  in  that  region  or  from  trau- 
matisms. The  branch  known  as  the  recuirrent  laryngeal  may 
be  damaged  by  aneurisms,  and  tumors  in  the  thorax.  The 
nerve  may  suffer,  in  common  with  other  nerves,  in  multiple 
neuritis  due  to  diphtheria,  alcohol,  and  septictemia,  and  is  at 
times  degenerated  in  locomotor  ataxia  or  other  degenerative 
disease.     Temporary  functional  derangements  probably  occur, 

1  Berl.  klin.  Woch.,  Dec.  23,  1895,  and  Deutsch.  Zeit.  fiir  Nervenheil- 
kunde,  vol.  ix,  No.  162,  1896. 


140  DISEASES  OF  CRANIAL  NERVES. 

due  to  the  absorption  of  toxic  substances  from  the  intestinal 
tract.  Tlie  hiryngeal  and  pharyngeal  distribution  may  be 
affected  by  cortical  lesions  in  their  centres. 

Diseases  of  the  tenth  nerve — symptoms :  These  may  be  gen- 
eral or  limited  to  the  functions  of  certain  branches,  and  may 
be  due  either  to  paralysis  or  irritation,  or  to  both  combined. 
Slowing  of  the  heart,  vomiting,  and  spasm  of  the  laryngeal 
muscles  are  the  chief  symptoms  of  irritation.  Rapidity  of 
the  heart's  action  and  paralysis  of  the  pharyngeal  and  lar- 
yngeal muscles  are  the  most  obvious  paralytic  symptoms. 

The  pharyngeal  branches :  If  a  paralytic  lesion  exists,  difi- 
culty  in  swalloiving  would  exist,  the  food  refusing  to  pass  into 
the  oesophagus.  This  symptom  is  only  marked  in  bilateral 
lesions.  Sjxiam  would  cause  temporary  inability  to  swallow. 
This  symptom  is  of  functional  origin  and  usually  is  due  to 
hysteria  (globus  hystericus). 

The  laryngeal  branches  :  The  motor  nerves  of  the  larynx  are 
the  superior  laryngeal,  which  supplies  the  crico-thyroid  mus- 
cle, and  the  inferior  laryngeal,  which  supplies  the  rest. 

In  addition  to  the  causes  above  enumerated,  paralysis  of 
these  muscles  frequently  is  due  to  hysteria  and  also  to  weak- 
ness from  anaemia  or  exhaustion,  congestion  or  inilammation, 
and  tumors  of  the  larynx.  In  some  cases  no  cause  can  be 
made  out. 

Laryngeal  paralysis  is  manifested  by  alteration  or  loss  of 
voice,  derangement  of  the  regulation  of  the  entrance  of  air 
during  respiration,  and  defects  in  the  movements  of  the  vocal 
cords. 

Of  the  latter,  according  to  the  degree  to  which  movement 
is  impaired,  there  are  three  types:  (1)  bilateral  abductor 
paralysis,  which  results  from  cold  or  local  inflammation,  cen- 
tral or  nerve  disease ;  (2)  unilateral  abductor  paralysis,  due 
to  pressure  on  the  recurrent  laryngeal ;  (3)  adductor  paralysis, 
usually  hysterical,  but  may  be  due  to  overuse  of  the  voice  or 
local  inflammation. 

The  symptoms  of  these  various  forms  are  given  in  the  fol- 
lowing table  of  Gowers : 


DISEASES  OF  THE  TENTH  NERVE. 


141 


Symptoms. 


No  voice ;  no  cough  ;  stridor 
only  on  deep  inspiration. 

Voice  low  pitcluMlaiid  lioarse  ; 
no  cough  ;  stridor  aljsentor 
slight  on  deep  breathing. 


Voice  little  changed ;  cough 
normal ;  inspiration  diffi- 
cult and  long,  with  loud 
stridor. 

Symptoms  inconclusive;  lit- 
tle affection  of  voice  or 
CDUgh. 

No  voice  ;  perfect  cough  ;  no 
stridor  nor  dyspncea. 


Signs. 


Both  cords  moderately  ab- 
ducted and  motionless. 

One  cord  moderately  abduc- 
ted and  motitjuless,  the 
uther  moving  freely,  and 
even  beyond  the  middle 
line  in  phonation. 

Both  cords  near  together, 
and  during  inspiration  not 
separated,  but  even  drawn 
nearer  together. 

One  cord  near  the  middle- 
line  not  moving  during  in- 
spiration,the  other  ndrnial. 

Cords  normal  in  position  and 
moving  normally  in  respi- 
ration ;  but  not  brought  to- 
gether on  an  attempt  at 
phonation.  i 


Lesion. 


Total  bilateral  palsy. 
Total  unilateral  palsy. 

Total  abductor  palsy. 


Unilateral 
palsy. 


abductor 


Adductor  palsy. 


Spasm  of  the  larynx  occurs  usually  in  rachitic  children,  but 
occasionally  may  occur  in  adults,  in  which  case  it  is  usually 
hysterical,  but  may  be  a  symptom  of  tetany  (laryngismus 
stridulus).  The  laryngeal  crises  of  locomotor  ataxia  are 
probably  due  to  spasm  of  the  adductors.  The  attacks  usu- 
ally occur  at  night,  and,  if  severe,  are  accompanied  by  cyano- 
sis and  dyspnoea. 

Anaesthesia  of  the  larynx  may  be  due  to  hysteria  or  to 
organic  lesion.  When  hysterical,  reflex  action  is  ])reserved; 
when  organic,  it  is  lost. 

The  cardiac  branches :  Irritation  of  these  nerves  or  their 
centres  produces  slowing  of  the  heart's  action,  often  seen  in 
meningitis,  cerebral  compression,  etc.  Slow  heart  may  occur 
in  disturbance  of  the  digestive  tract  due  to  auto-intoxication. 
Paralysis  of  these  branches  causes  the  opposite  effect — /".  e., 
rapid  action,  most  often  seen  in  diphtheritic  neuritis,  less  fre- 
quently from  other  toxic  influences.  When  the  affection  is 
unilateral  not  much,  if  any,  disturbance  will  be  noted.  Disturb- 
ance of  nutrition  of  the  centres  or  trunk,  as  in  neurasthenia, 
may  cause  an  irregular  action.  Sensory  disturbances  of  the 
branches  are  thought  to  cause  pseudo-anginal  attacks. 

(Esophageal  and  gastric  branches  :  Paralytic  disturbance  of 
the  cesopliageal  branches  is  rare,  and  if  present  would  occa- 
sion difficulty  in  swallowing.  Spasm,  usually  due  to  hysteria, 
is  more  common.     Care  must  be  taken  not  to  confound  tliis 


142  DISEASES  OF  CRANIAL  NERVES. 

with  organic  strititure.  The  administration  of  ether  in  hys- 
terical spasm  will  cause  relaxation  of  the  spasm,  when  a  bou- 
gie can  be  passed.  Vomiting  is  due  either  to  reflex  stimula- 
tion, or  to  direct  irritation  of  the  nerve-roots,  as  in  meningitis 
or  tumor.  Gastralgia  in  some  instances  is  thought  to  be  a 
neuralgia  of  these  branches ;  in  others,  it  may  be  due  to 
the  direct  irritation  of  their  peripheral  endings.  The  "  gas- 
tric crises  "  of  locomotor  ataxia  are  due  to  irritation  of  these 
branches. 

Diseases  of  the  tenth  nerve — prognosis  :  The  prognosis  is 
l)ad  in  most  cases  of  organic  origin,  death  sooner  or  later 
being  the  result.  Functional  disturbances,  while  they  do  not 
threaten  life,  are  often  most  obstinate  and  annoying. 

Diagnosis  :  To  determine  the  seat  of  the  lesion,  the  nature 
and  distribution  of  the  symptoms  and  associated  symptoms 
must  be  taken  into  account.  Disease  of  the  main  trunk  is  rare. 
Nuclear  disease  is  bilateral  and  associated  with  disease  of  the 
ninth  and  twelfth  nerves.  Disease  of  one  recurrent  laryn- 
geal usually  denotes  thoracic  disease.  A  lesion  in  the  neck 
making  pressure  on  the  nerve  is  usually  apparent.  Altered 
functions  due  to  hysteria  would  be  accompanied  by  other  evi- 
dences of  hysteria. 

The  treatment  is  mainly  that  of  the  cause,  which  must  be 
removed  when  possible.  Electricity,  preferably  faradism,  is 
often  beneficial  in  cases  of  hysterical  paralysis.  It  may  be 
applied  one  pole  within  the  larynx  or  both  applied  externally, 
one  to  each  side  of  the  organ.  When  the  paralysis  is  second- 
ary to  inflammation  electricity  and  strychnine  are  indicated. 

THE  ELEVENTH  OR  SPINAL  ACCESSORY  NERVE. 

Anatomy :  The  cerebral  origin  of  the  nerve  is  found  in  a 
nucleus  in  the  medulla  a  short  distance  below  the  nucleus 
ambiguus.  Fibres  from  it  join  the  tenth  nerve.  Tlie  spinal 
portion  arises  from  the  anterior  cornua  of  the  upper  end  of  the 
spinal  cord  as  far  down  as  the  sixth  or  seventh  cervical  seg- 
ment. The  i-oots  ascend  into  the  cranial  cavity,  but  leave  it 
again  and  supply  tlie  sterno-cleido-mastoid  and  trapezius 
muscles.      Its  functions  are  motor. 

Paralysis  of  the  eleventh  nerve — etiology :   As  it  leaves  the 


PARALYSIS  OF  THE  ELEVENTH  NERVE.  143 

cranium  it  may  be  involved  in  the  exudate  of  basal  menin- 
gitis. The  cells  in  the  gray  matter  may  be  the  seat  of  hem- 
orrhage or  of  an  acute  inflammation  (acute  poliomyelitis),  or 
maybe  the  seatof  chronic  degeneration  (progressive  muscular 
atrophy),  due  to  similar  causes  that  produce  nuclear  disease 
elsewhere.  It  may  suffer  in  caries  of  the  cervical  vertebra 
or  from  tumors  outside  the  skull,  and  may  be  the  seat  of 
a  rheumatic  neuritis. 

Paralysis  of  the  eleventh  nerve — symptoms :  Partdvsis  of  one 
sterno-mastoid '  causes  difficulty  in  turning  the  head  to  the 
opposite  side  through  the  action  of  the  non-[)aralyzed  muscle, 
by  which  the  head  may  be  turned  toward  the  paralyzed  side. 
Only  the  upper  portion  of  the  trapezius  is  supplied  by  the 
eleventh.  Paralysis  of  this  portion  would  be  evidenced  by 
slight  drooping  of  the  shoulder  and  im])airment  of  the  power 
of  elevating  the  arm.  In  bilateral  paralysis,  the  head  is  with- 
out support  and  consequently  cannot  be  held  erect. 

Diagnosis — prognosis  :  If  due  to  basal  lesion,  the  several 
symptoms  of  meningitis  would  be  present,  and  other  nerves 
would  probabl}^  be  affected.  Cervical  caries  is  accompanied 
by  rigidity,  tenderness,  and  pain  on  jarring.  If  due  to  acute 
nuclear  lesion,  the  symptoms  would  be  those  of  acute  polio- 
myelitis ( p.  207).  A  chronic  nuclear  lesion  is  progressive, 
and  other  muscles,  would  soon  be  affected.  Hemorrhage 
would  be  sudden  in  onset,  probably  following  injury.  If  due 
to  a  basal  meningitis  or  cervical  caries,  remedying  of  these 
conditions  Mill  likely  be  folloM'ed  by  a  return  of  power. 
Chronic  nuclear  lesions  are  incurable. 

The  treatment  is  that  of  the  cause.  Electricity,  massage, 
and  strychnine  should  be  employed  in  peripheral  cases. 

Spasm  of  the  muscles  supplied  by  the  eleventh  nerve — etiology : 
Spasm  of  these  muscles — commonly  kuoAvn  as  torticollis  or 
wry  neck — may  be  acute  or  chronic ;  tonic  or  clonic.  Tonic 
spasm  when  acute  is  usually  caused  by  an  inflammation  of  the 
muscles  and  nerve,  due  to  cold.  This  is  familiarly  known  as 
"  stiff'  neck."  The  sjiasm  may  be  due  to  focal  irritati^•e 
lesions  in  one  of  several  locations — viz.,  the  spinal  cord  above 
the  fifth  or  sixth  cervical  segments ;  or  extra-medullary  le- 
sion ;  new  growths  or  hemorrhage  ;  meningitis  or  bone-dis- 
ease, in  the  upper  part  of  the  vertebral  canal  ;  in  the  medulla  ; 


144  DISEASES  OF  CRANIAL  NERVES. 

in  the  trunk  of  the  nerve ;  in  any  of  the  nerves  which  anas- 
tomose with  the  spinal  accessory,  and  are  connected  with  it 
in  the  spinal  cord ;  in  the  cortical  centres.  A  lesion  in  one 
of  these  situations  according  to  its  nature,  whether  of  rapid 
or  slow  development,  would  cause  either  acute  or  chronic 
spasm,  which  may  be  either  tonic  or  clonic  combined.  In  the 
great  majority  of  cases  no  cause  can  be  determined  and  no 
lesion  can  be  found,  but  the  trouble  probably  lies  in  the  cor- 

FiG.  31. 


Spasmodic  torticollis. 

tical  centres.  These  cases  usually  come  on  in  middle  life. 
Those  who  have  a  neurotic  ancestry  are  especially  predisposed. 
Overwork,  exposure,  debility,  neurasthenia,  reflex  disturb- 
ances, as  bad  teeth  or  eye-strain,  appear  in  some  cases  to  be 
exciting  causes.  A  number  of  cases  have  been  observed  in 
weavers.     The  affection  may  also  be  hysterical. 

Symptoms :  In  the  tonic  variety  (Fig.  31)  when  unilateral. 


TORTICOLLIS.  145 

the  head  is  rotated  so  that  the  chin  points  npwardand  toward 
tiie  opposite  side,  the  occiput  being  drawn  toward  the  shoulder 
of  the  diseased  side.  When  the  trapezius  alone  is  affected 
the  head  will  be  drawn  backward  and  the  shoulder  elevated. 
Attempts  to  restore  the  head  to  its  normal  position  will  cause 
pain  in  the  affected"  muscle. 

In  the  donie  form  the  head  is  thrown  into  the  position 
above  described  at  more  or  less  frequent  intervals.  At  first 
the  intervals  may  be  long,  but  as  the  disease  progresses  they 
become  sliorter.  In  severe  cases  the  posterior  rotators  which 
are  supplied  by  the  upper  cervical  nerves  are  also  involved. 
These  muscles  pull  the  head  backward  and  rotate  it  toward 
the  affected  side,  which  would  neutralize  the  action  of  the 
sterno-mastoid.  In  most  cases,  however,  the  muscles  of  the 
opposite  side  are  affected,  and  hence  ^\fould  exaggerate  the 
spasm  produced  by  the  sterno-mastoid,  while  the  head  is 
pulled  back  more  than  in  pure  spinal  accessory  spasm.  The 
face-,  shoulder-,  arm-,  and  other  muscles  may  also  take  part 
in  the  spasm.  It  is  more  aggravated  during  movements  of 
other  muscles  and  usually  disappears  during  sleep.  The 
affected  muscles  become  hard  and  prominent  during  the 
seizure.  Bilateral  spasm  is  usually  confined  to  the  sterno- 
mastoid.  By  it  the  head  is  pulled  forward  and  downward, 
the  chin  pointing  toward  the  sternum.  Electrical  reactions 
are  normal  or  increased.  In  time  the  muscles  hypertrophy. 
Young  children  are  sometimes  met  with  who  paroxysmally 
nod  the  head  for  a  minute  or  more  several  times  during  the 
day  (eclampsia  nutans).  This  is  thought  to  be  due  to  a  bi- 
lateral clonic  sterno-mastoid  spasm. 

Diagnosis :  Sterno-mastoid  spasm  may  be  confounded  with 
spasm  of  the  splenius  capitis  of  the  opposite  side.  In  this 
the  head  is  drawn  backward  toward  the  affected  side,  while 
the  chin  is  depressed  and  directed  toward  the  corresponding 
shoulder.  The  muscle  can  be  felt  as  a  hard  roll  beneath  the 
anterior  border  of  the  trapezius  (Erb).  In  spasm  of  the 
obliquus  capitis  inferior  the  head  is  rotated  without  elevation 
or  depression  of  the  chin.  Spasm  of  these  muscles  may, 
however,  be  associated  with  spinal  accessory  disease.  Spasm 
due  to  organic  disease  in  one  of  the  situations  mentioned 
under  etiology  would  be  accompanied  by  other  symptoms  of 
10— N.  D. 


146  DISEASES   OF  CRANIAL  NERVES. 

such  disease.  Tumor  or  vertebral  disease,  with  meningitis  in 
the  cervical  region,  is  probably  the  most  common  causes  of 
such  spasm.  The  spasm  may  rarely  be  a  hysterical  phe- 
nomenon, but  the  stigmata  of  that  disease  would  probably  be 
also  present. 

Prognosis :  Spinal  accessory  spasm  is  one  of  the  most  stub- 
born affections  that  we  have  to  treat.  Relief  may  be  ob- 
tained, but  can  never  be  promised.  The  longer  the  trouble 
has  lasted  the  worse  the  chances  for  relief  by  medical  meas- 
ures. As  regards  life  the  prognosis  is  good,  excepting  when 
due  to  organic  disease  whi<ih  itself  is  dangerous  to  life. 

Treatment:  In  cases  due  to  organic  disease  treatment  must 
be  directed  to  the  cause.  In  the  so-called  functional  spasm 
sources  of  reflex  irritation  must  be  looked  for  and  removed 
if  found.  Benefit  may  be  derived  from  prolonged  and  abso- 
lute rest,  with  the  head  on  a  low  pillow ;  the  bed  must  be 
left  for  no  purpose  whatsoever  and  the  patient  should  be  fed 
by  the  nurse.  Tincture  of  gelsemium  in  large  doses  (gtt.  xv, 
three  to  four  times  daily)  and  atropine  in  increasing  doses, 
preferably  hypodermatically  into  the  affected  muscles  once 
daily,  may  give  some  relief.  Massage  is  of  benefit,  especially 
when  used  in  connection  Avith  rest.  Also  the  constant  gal- 
vanic current,  the  anode  over  the  affected  muscles  and  the 
cathode  at  a  remote  point,  is  worth  a  trial.  Counterirritation 
by   means   of  the  actual    cautery   has   been   recommended. 

When  medical  means  have  been  given  a  fair  trial  and  no 
relief  has  been  obtained,  resection  of  the  spinal  accessory 
and  posterior  branches  of  the  upper  cervical  nerves,  and  even 
of  the  muscles  themselves,  may  relieve,  but  seldom  cures. 

THE  TWELFTH  OR  HYPOGLOSSAL  NERVE. 

Anatomy :  The  cortical  centres  for  the  twelfth  nerve  are 
situated  in  the  extreme  lower  part  of  the  central  convolutions. 
From  these,  fibres  run  through  the  internal  capsule  in  close 
relation  with  those  of  the  pyramidal  tract  and  finally  reach 
their  nuclei,  the  cells  of  which  begin  in  the  lower  ])art  of 
the  medulla,  near  the  middle  line  of  the  floor  of  the  fourth 
ventricle  and  extend  upward  as  far  as  the  strise  acusticse. 
The  axons  of  these  cells  form  the  hypoglossal  nerve,  which 


PARALYSIS  OF  THE  TWELFTH  NERVE.  147 

is  the  motor  nerve  of  tlie  tongue,  supplying  all  niuseles  of 
the  tongue  excepting  the  palato-glossus  and  pharvngeo-glossus. 
This  nerve  has  connections  with  the  pneuniogastric,  lingual, 
up])er  three  cervical  nerves,  and  sympathetic. 

Paralysis  of  the  twelfth  nerve — etiology :  l^aralvsis  of  the 
functions  of  the  twelfth  nerve  may  be  due  to  a  lesion  situ- 
ated anywhere  between  the  cortex  and  its  perijiheral  termina- 
tion— i.  e.,  either  a  supranuclear,  nuclear,  or  intranuclear 
lesion.  Supranuclear  disease  is  the  most  common,  and  may 
be  caused  by  hemorrhage,  softening,  tumor,  or  abscess.  Nu- 
clear lesions  may  be  acute  or  chronic,  and  are  due  to  the  same 
causes  that  produce  nuclear  lesions  elsewhere  (bulbar  })alsies). 
They  are  practically  always  associated  with  disease  of  the 
nuclei  of  the  ninth  and  tenth  nerves.  Infranuclear  disease 
may  be  caused  by  softening  or  tumor  in  the  medulla,  by 
meningitis  or  tumor  at  the  base  of  the  brain,  by  penetrating 
wounds  or  tumors  in  the  neck,  and  vertebral  disease. 

Symptoms:  The  principal  symptom  is  impairment  of  the 
power  of  moving  the  tongue.  If  unilateral,  the  base  while 
at  rest  is  higher  on  the  paralyzed  than  on  the  sound  side. 
When  the  tongue  is  protruded  it  deviates  toward  the  para- 
lyzed side,  being  drawn  there  by  the  genio-hyoglossus  on  the 
normal  side.     Mastication  and  deglutition  are  interfered  with. 

In  bilateral  disease  the  tongue  can  either  not  be  protruded 
at  all  or  else  but  slightly,  and  then  cannot  be  kept  so  long.  No 
atrophy  occurs  in  supranuclear  lesion ;  but  in  nuclear  and 
infranuclear  disease  it  does,  the  tongue  presenting  a  wasted 
and  wrinkled  appearance,  and  fibrillary  tremors  are  present. 
Common  sensibility  and  taste  are  not  interfered  with. 

Diagnosis :  There  should  be  no  difficulty  in  recognizing 
that  paralysis  exists.  Supranuclear  lesions  are  usually  asso- 
ciated with  hemiplegia.  Nuclear  disease  is  practically  al- 
ways bilateral  and  is  associated  with  weakness  of  the  lips, 
pharynx,  larynx,  and  possibly  other  muscles  (progressive 
muscular  atroph}).  Crossed  paralysis,  of  the  tongue  on  one 
side  and  the  arm  and  leg  on  the  other,  is  probably  due  to  an 
involvement  of  the  root-fibres  in  the  medulla.  Unilateral 
])aralysis  associated  with  that  of  neighboring  cranial  nerves 
(ninth,  tenth)  suggests  disease  at  the  base. 

Prognosis — treatment :  When  a  supranuclear  palsy  is  due  to 


148  DISEASES   OF  CRANIAL   NERVES. 

hemorrhage  or  softening  (apoplexy),  the  tongue  often  recovers 
power.  When  due  to  the  other  causes  of  such  paralysis  the 
condition  is  permanent.  In  nuclear  disease  the  prognosis  is 
bad.  If  the  paralysis  is  the  result  of  an  infranuclear  lesion 
(if  the  lesion  can  be  removed,  as  a  syphilitic  meningitis), 
the  outlook  for  recovery  is  fair;  otherwise  it  is  bad.  The 
treatment  is  that  of  the  morbid  process  causing  it — i.  e.,  the 
treatment  of  meningitis,  syphilis,  apoplexy,  bulbar  palsy,  or 
neuritis. 


CHAPTER    VIII. 

DISEASES  OF  THE  SPINAL  NERVES. 
THE  CERVICAL  NERVES. 

Cervico-occipito  Neuralgia. 

Etiology — symptoms :  Neuralgia  of  the  first  four  cervical 
nerves,  especially  the  great  occipital  branch,  is  produced  by 
the  general  causes  of  neuralgias  elsewhere.  It  should  be 
remembered  that  pain  in  the  distribution  of  these  nerves 
may  be  due  to  caries  of  the  cervical  vertebrae.  It  is  often 
associated  with  neuralgia  of  the  fifth  and  with  torticollis. 

The  pain  is  felt  in  the  occipital  region  and  sometimes  in 
the  posterior  parietal  region  in  addition.  It  is  often  bilateral. 
The  scalp  may  be  tender  to  pressure.  Tender  points  are 
found  :  (1)  at  the  angle  of  the  great  occipital  between  the 
mastoid  and  the  spine ;  (2)  in  the  triangle  between  the  trape- 
zius and  sterno-mastoid  occupied  by  the  cervical  nerves ; 
(3)  above  the  parietal  eminence. 

Prognosis — treatment :  Excepting  when  the  disease  comes 
on  late  in  life  and  is  rebellious  to  treatment,  the  prognosis  is 
good. 

Counterirritation  to  the  neck  and  occiput  by  means  of  the 
actual  cautery  or  fly-blister  is  of  great  service.  Otherwise 
the  treatment  is  the  same  as  that  detailed  for  neuralgia  of 
the  fifth  nerve. 

Paralysis  of  the  Phrenic  Nerve. 

Etiology — symptoms :  The  phrenic  nerve  is  derived  from 
the  third,  fourth,  and  fifth  cervical  nerves,  which  emerge 
from  the  cord  on  a  level  with  the  second,  third,  and  fourth 
cervical  vertebrse.  Paralysis  of  the  nerve  is  usually  due  to 
disease  of  the  cord,  or  its  membranes,  or  of  the  vertebrse.  It 
is  occasionally  injured  in  wounds  of  the  neck,  and  may  be 

149 


150  DISEASES  OF  THE  SPINAL  NERVES. 

compressed  by  tumors,  aneurisms,  etc.,  in  its  course  through 
the  thorax.  Paralysis  due  to  neuritis  may  follow  exposure 
to  cold,  and  may  be  associated  with  multiple  neuritis  due  to 
diphtheria  or  beri-beri.  Paralysis  of  both  nerves  causes  in- 
action of  the  diaphragm,  manifested  by  the  upper  part  of  the 
abdomen  not  advancing  (even  being  retracted)  during  inspira- 
tion. On  exertion  there  will  be  dyspnoea  and  weakness  of 
the  voice.  Bronchitis  and  pneumonia  are  more  apt  to  occur, 
and  are  more  dangerous  when  paralysis  of  these  nerves  exists. 
Unilateral  paralysis  does  not  cause  much  inconvenience,  and 
is  difficult  to  discover. 

Paralysis  of  the  phrenic  nerve — diagnosis :  It  must  be  re- 
membered that  hysterical  individuals  may  breathe  for  a  time 
without  using  the  diaphragm.  Petraction  of  the  diaphragm 
may  be  present  in  peritonitis  and  diaphragmatic  pleurisy, 
owing  to  pain  caused  by  such  movement.  Degeneration  of 
the  muscle  itself  may  cause  decrease  in  its  power.  A  bilat- 
eral paralysis  is  usually  due  to  disease  of  the  cord,  mem- 
branes, or  vertebrae,  or  to  multiple  neuritis.  When  due  to  dis- 
ease of  the  cord  or  membranes  paralyses  of  other  parts  below 
the  seat  of  the  lesion  would  be  present.  In  bone  disease 
there  would  be  rigidity  of  the  neck-muscles  and  tenderness 
to  pressure  or  jarring.  Unilateral  paralysis  is  due  to  either 
traumatism,  neuritis  from  exposure,  compression  by  tumors, 
or  aneurism  in  the  neck  or  thorax. 

The  prognosis  depends  upon  the  cause.  Bilateral  palsy  is 
often  fatal. 

The  treatment  also  is  that  of  the  cause. 


THE  BRACHIAL  PLEXUS. 

Paralysis  of  the  Posterior  Thoracic  Nerve. 

Etiology :  The  posterior  thoracic  nerve  arises  from  the  fifth 
and  sixth  cervical  roots,  and  sometimes  from  the  seventh  also. 
It  supplies  the  serratus  magnus  muscle. 

The  causes  of  paralysis  of  its  functions  are  usually  neuritis 
due  to  contusion  or  a  blow  on  the  neck,  by  pressure  from  a 
heavy  weight  carried  on  the  shoulder,  by  violent  muscular 


PARALYSIS  OF  THE  CIRCUMFLEX  NERVE.         151 

effort  as  raising  a  heavy  weight,  by  exposure  to  cold,  and 
possibly  to  a  toxaemia.' 

The  symptoms  of  paralysis  of  the  serratus  niagnus  are : 
(1)  Rotation  of  the  scapula  upon  its  vertical  axis  when  the 
arm  is  put  forward,  with  recession  of  the  edge  of  the  scapula 
from  the  thorax  ;  the  scapula  then  resembles  a  wing,  and  has 
been  termed  the  "winged  scapula";  (2)  rotation  inward  and 
upward  of  the  lower  angle  of  the  scapula  when  the  arm 
is  advanced  ;  (3)  Aveakening  or  loss  of  the  power  of  elevating 
the  arm  above  the  shoulder.  The  paralysis  is  usually  unilat- 
eral and  may  be  accompanied  by  pain  in  the  neck  and  shoulder. 
An  uncomplicated  palsy  of  this  nerve  is  rare. 

Paralysis  of  the  Infrascapular  Nerve. 

Etiology — symptoms  :  This  nerve  also  arises  from  the  fifth 
and  sixth  cervical  roots.  It  supplies  the  supraspinatus  and 
infraspinatus  muscles.  Isolated  paralysis  of  the  muscles  is 
rare,  but  is  frequently  found  associated  with  paralysis  of  the 
deltoid  due  to  injury  to  the  nerve  caused  by  dislocation  of 
the  shoulder-joint.  Paralysis  of  these  muscles  causes  loss  of 
the  power  of  outward  rotation  of  the  humerus,  which  is  mani- 
fested in  loss  of  the  power  to  carry  the  hand  from  left  to 
right  in  writing. 

Paralysis  of  the  Circumflex  Nerve. 

Etiology — symptoms :  The  circumflex  nerve  arises  from  the 
posterior  cord  of  the  brachial  plexus,  which  is  formed  by  the 
fifth,  sixth,  and  seventh  cervical  roots.  It  supplies  the  deltoid 
and  teres  minor  muscles.  The  nerve  is  usually  injured  by 
falls  or  blows  upon  the  shoulder  or  by  dislocation  of  the 
joint.     It  may  be  the  seat  of  a  rheumatic  neuritis. 

In  paralysis  of  this  nerve  there  is  loss  of  the  power  of 
raising  the  arm  into  or  above  the  horizontal  position.  Wast- 
ing of  the  deltoid  occurs,  causing  alteration  in  the  appearance 
of  the  shoulder ;  if  extreme,  there  may  be  a  depression  be- 
tween the  acromion  process  and  the  head  of  the  humerus.   The 

^  A  case  has  recently  been  reported  of  uncomplicated  paralysis  of  the 
serratus  magnus  following  influenza.  Miinchener  medicin.  Wochenschrift, 
Sept.  6,  1898 ;  quoted  in  Phi!a.  Med.  Jour.,  Oct.  5,  1898. 


162 


CUTANEOUS  DISTRIBUTION  OF  NERVES. 


Fig.  32. 


Great  occipital,  posterior  branch  of 
second  cervical 


Posterior  branches  of  spinal  nerves 


Lateral  liraiicbes  of  intewostal  nerves 

Hiac  brancU  of  ilio-inguinal  L.  P 
Second  liinibar 

Inferior  hemorrhoidal  of  piidic  S.  P. 

Superficial  perineal  of  pudic  and 
inferior  pudendal  of  small 
sciatic  S.  P. 

Interior  gluteal  of  small  sciatic  S.  P. 


Internal  cutaneous  L.  P. 


Internal  saphenouSil/.  P. 


Auriculotemporal  3  V 
Small  occipiti^l  C.  P. 

Great  auricular  C.  P- 


SupradavicHl.ir 
C.  P.,  acromial 
I)  ranch 

Secoud  dorsal 

Circumflex  B.  P 


Intercostohumeral 

loteriial  ciitaneniis 

of  muscuiospiral 

B.  P. 
Nerves  of  Wrisberg 

B.  P. 
External  cutaneous 

of  muscuiospiral 

B.  P. 
Internal  cutaneous 

B.  P. 
Musculocutaneous 

B.  P 


Ulnar  B.  P 


External  cutaneous  L.  P. 


Brandies  from  external 
jiopliical  S.  P 


External  saphenous  S.  P. 


Posterior  tibial  S.  P. 


Cutaneous  distribution  of  nerves  (after  Flower). 


CUTANEOUS  DISTRIBUTION  OF  NERVES. 


153 


Fig.  33. 


Aiiriciilutcmporal  3  V. 

<;rcat  oucij>it:il 

Lacrimal  1  V. 

Teniporoinalar  2  V 

Sniali  occipital  C.  P 

lircat  auricular  C.  1* 


Acrumial  branch 
Middle  branch 


Circumflex  B.  P 
Iiltercostohu 

Nerve  of  Wrisbere 

H.  I'. 
Kxtornal cutaneous 
of  musculospiral 
«.  1'. 

Intcrnsil  ciiinnenus 
B.  P 

JIusciilocntaiicou' 
B.  P. 


Branclirs  from  external 
Jiopliteal  S.  V 


Musculocutaneous  S.  P. 

l;xt«rnal  sajilienous  S.  P 
Ajiferiot tibials.  P. 


(iupra^orbftal  t  V. 

Supratrochlear  1  V 
Intratrochlear  1  V 
Nasal  1  V 
Infra-orbital  2 
Buccal  3  V. 
Mental  3  V. 

Superficial  cervical  C.  F. 


Sternal  branch 


Anterior  branches  of  intercostal 
nerves 

Lateral  branches  of  intercostal 
nerves 


Iliohypogastric  I,.  P. 
Dorsalis  penis  of  pudic  S.  P. 
Ilioinguinal  I-.  P 

Geuiloorural  L.  P 
Middle  cutaneous  L.  P. 
Internal  cutaneous  L.  P. 


Internal  saphenous  L.  P. 


Cutaneous  distribution  of  nerves  (after  Flower). 


154  DISEASES  OF  THE  SPINAL  NERVES. 

electrical  reactions  are  altered  in  degree  according  to  the  ex- 
tent of  the  damage.  Trophic  changes  may  occur  in  the 
joint  and  adhesions  may  form.  Care  must  be  taken  not  to 
confound  loss  of  motion  from  paralysis  of  the  deltoid  with 
anchylosis  of  the  joint  due  to  an  arthritis.  In  the  latter  case 
there  would  likely  be  pain  increased  by  motion,  and  passive 
movement  of  the  arm  would  move  the  scapula  also.  In  some 
cases  there  is  loss  of  sensation  in  the  upper  part  of  the  arm 
over  the  muscles  (Figs.  32  and  33). 

Paralysis  of  the  Musculo-cutaneous  Nerve. 

Etiology — symptoms  :  This  nerve  arises  from  the  outer  cord 
of  the  brachial  plexus,  which  is  formed  by  a  union  of  the 
fifth  and  sixth  cervical  roots.  It  supplies  the  biceps,  and 
brachialis  anticus  muscles.  Paralysis  of  these  muscles  causes 
loss  of  the  power  of  flexing  the  forearm  upon  the  arm,  most 
marked  when  the  forearm  is  supinated  and  the  supinator 
longus  cannot  act  as  a  flexor.  There  may  or  may  not  be 
anaesthesia.  When  present  it  is  found  on  the  outer  half  of 
the  forearm  in  front  and  behind  and  over  the  arm  in  its 
lower  part  and  outer  side  (Figs.  32  and  33).  The  nerve  is 
rarely  paralyzed  by  itself. 

Paralysis  of  the  Musculo-spiral  Nerve. 

Etiology — symptoms :  The  musculo-spiral  nerve  is  derived 
from  the  posterior  cord  of  the  brachial  plexus.  It  supplies 
the  triceps,  anconeus,  supinator  longus,  and  extensor  carpi 
radialis  longior,  and  by  means  of  its  posterior  interosseous 
branch  all  the  extensor  muscles  of  the  radial  and  posterior 
brachial  regions.  Paralysis  of  this  nerve  is  common ;  it  is 
frequently  injured  by  pressure  (see  Pressure-palsy).  It  may 
be  torn  in  fractures  of  the  humerus,  or  pressed  upon  by 
callus,  or  divided  by  incised  wounds.  It  is  also  the  cause 
of  the  paralysis  which  sometimes  occurs  after  anaesthesia,  and 
is  then  due  to  overextension  of  the  arm.  It  is  frequently 
involved  with  other  nerves  in  multiple  neuritis. 

In  paralysis  of  the  nerve  high  up  in  the  region  of  the 
plexus  extension  of  the  forearm  upon  the  arm  is  impossible; 
the  hand  cannot  be  extended   upon  the  forearm  and  drops 


PARALYSTS  OF  THE  MUSCULO-SPIRAL   NERVE.      155 

when  the  arm  is  held  in  a  horizontal  position  (Fig.  34).  The 
fingers  are  flexed  at  their  distal  points,  and  owing  to  loss 
of  the  resistance  of  the  extensors  the  grij)  is  weakened. 
Supination  is  impaired.  If  long  continued,  the  excessive 
flexion  of  the  carpus  leads  to  undue  prominence  of  the  carpal 
bones  and  the  synovial  sacs  at  the  back  of  the  wrist.  If  the 
nerve   is   afiected   low  down   or   the   posterior  interosseous 

Fig.  34. 


Wrist-drop  in  musculo-spiral  paralysis  (Leube). 


branch  is  alone  affected,  the  triceps  and  supinator  longus 
escape. 

Atrophy  occurs  and  the  muscles  present  various  degrees  of 
changed  electrical  reaction. 

Loss  of  sensation,  when  it  occurs,  varies  in  location.  After 
division  of  the  nerve  above  the  origin  of  its  cutaneous 
branches  there  is  loss  of  sensation  in  the  outer  part  of  the 
forearm  from  the  level  of  the  insertion  of  the  deltoid  to  the 
external  condyle  of  the  humerus ;  and  on  the  back  of  the 
forearm  on  the  outer  side  above,  fading  into  normal  at  the 


156  DISEASES  OF  THE  SPINAL  NERVES. 

lower  third.  The  skin  is  anaesthetic  on  the  dorsal  surface  of 
the  thumb  and  the  metacarpal  bones  of  the  thumb,  index 
and  middle  fingers  (Figs.  32  and  33). 

Paralysis  of  the  Median  Nerve. 

Etiology — symptoms :  The  median  nerve  arises  from  the 
outer  and  inner  cords  of  the  brachial  plexus.  The  latter  is 
formed  by  the  eighth  cervical  and  first  dorsal  roots.  It  sup- 
plies the  flexors  of  the  fingers  (excepting  the  ulnar  half  of 
the  deep  flexor),  the  pronators,  the  flexor  carpi  radialis,  the 
two  outer  lumbricals,  and  all  the  muscles  of  the  ball  of  the 
thumb,  abductor  pollicis  and  the  outer  half  of  the  flexor  brevis 
pollicis.  The  median  nerve  is  frequently  injured  or  divided 
by  wounds  or  fractures  of  the  forearm,  and  injured  by  blows. 
Iit>has  been  rarely  injured  by  excessive  action  of  the  pronator 
radii  teres,  and  possibly  may  be  the  seat  of  a  rheumatic  neu- 
ritis. Paralysis  of  all  the  muscles  supplied  by  this  nerve, 
which  would  occur  when  the  lesion  is  high  up,  would  cause 
diminution  of  the  power  of  flexing  and  pronating  the  fore- 
arm. The  thumb  cannot  be  brought  in  contact  with  the  tips 
of  the  fingers.  There  is  inability  to  flex  the  second  pha- 
langes upon  the  first,  and  in  the  index  and  middle  fingers 
there  is  loss  of  flexion  of  the  third  phalanges. 

If  the  lesion  is  low  down,  just  above  the  w^ist,  loss  of 
power  in  the  thumb  and  fingers,  as  described  above,  would 
only  be  present  unless  an  ascending  neuritis  occurred. 

Loss  of  sensation,  if  present,  is  limited  to  the  radial  side 
of  the  palm  and  the  palmar  surfaces  of  the  thumb,  index 
and  middle  fingers,  and  the  radial  side  of  the  ring-finger. 
On  the  dorsal  surface  loss  of  sensation  occurs  in  the  index 
and  middle  fingers,  and  on  the  radial  side  of  the  ring-finger 
for  a  variable  distance  (Figs.  32  and  33). 

Paralysis  of  the  Ulnar  Nerve. 

Etiology — symptoms  :  The  ulnar  nerve  arises  from  the  inner 
cord  of  the  brachial  plexus.  It  supplies  the  ulnar  half  of 
the  flexor  profundus  digitorum  ;  tlie  flexor  carpi  ulnaris  ;  all 
the  muscles  of  the  little  finger ;  all  the  interossei ;  the  two 


PARALYSIS  OF  THE   ULNAR  NERVE. 


157 


ulnar  lumbricales  ;  the  adductor  pollicis  ;  and  the  inner  head 
of  the  flexor  brevis  polhcis. 

The  nerve  is  frequently  injured  by  M'ounds  of  the  forearm, 
especially  at  the  wrist ;  by  fractures  of  the  forearm,  and  at 
the  back  of  the  elbow  by  pressure  or  blows.  Long-continued 
flexion  of  the  elbow  lias  caused  ulnar  paralysis.  There  would 
be,  if  injured  high  up,  impaired  flexion  of  the  hand  upon 
the  arm,  loss  of  power  of  flexing  the  first  or  extending  the 
second  and  third  phalanges,  of  the  power  of  opposing  the 
thumb  to  the  index  finger,  and  of  abducting  and  adducting 
the  fingers.     If  the  paralysis  lasts  any  time,  the  hand,  owing 

Fig.  35. 


Position  of  wrist,  hand,  and  fingers  in  ulnar  paralysis  (Leube). 


to  the  action  of  antagonistic  muscles,  assumes  a  characteristic 
attitude.  The  hand  is  slightly  over-extended  and  inclines  to 
the  radial  side  of  the  forearm.  Owing  to  the  wasting  of  the 
interossei  there  are  depressions  between  the  metacarpal  bones, 
(^specially  marked  on  the  radial  side  of  the  index  finger 
on  the  dorsal  surface.  The  loss  of  power  in  the  interossei 
which  flex  the  first  phalanges  causes  their  hyperextension, 
owing  to  the  action  of  the  extensor  muscles  of  those  pha- 
langes which  are  supplied  by  the  musculo-spiral.  For  a  simi- 
lar reason  there  is  hyperflexion  of  the  second  and  third  pha- 


158  DISEASES  OF  THE  SPINAL  NERVES. 

langes  that  are  extended  by  the  interossei,  owing  to  the  action 
of  their  flexors,  which  are  suppHed  by  the  median.  This  de- 
formity is  known  as  the  "  bird-claw  hand "  or  "  claw-Kke 
hand "  (Fig.  35).  When  the  lesion  is  low  down,  above  the 
wrist,  impairment  of  the  functions  of  these  intrinsic  muscles 
of  the  hand  alone  occurs. 

If  ancesthesia  occurs,  it  is  usually  confined  to  the  palmar 
and  dorsal  surfaces  of  the  little  and  ulnar  half  of  the  ring- 
fingers  and  corresponding  portion  of  the  hand  (Figs.  32  and 
33). 

Combined  Paralysis  of  the  Brachial  Plexus. 

Etiology :  Paralysis  caused  by  involvement  of  all  or  nearly 
all  of  the  branches  of  the  brachial  plexus  is  common.  The 
nerve-roots  forming  the  plexus  may  be  damaged  within  the 
spinal  canal  by  cervical  meningitis  or  tumor  in  that  region, 
and  by  disease  of  the  vertebrae.  The  causes  which  concern 
us  here  are  those  occurring  external  to  the  spinal  canal. 
These  are  :  (1)  dislocations  of  the  head  of  the  humerus  ;  (2) 
fractures  of  the  bones  of  the  arm ;  (3)  ascending  neuritis ; 
(4)  injuries  received  during  birth  or  later  in  life ;  (4)  new 
growths  situated  in  the  neck  ;  (6)  primary  brachial  neuritis. 

Symptoms :  The  symptoms  of  continued  paralysis  would, 
of  course,  vary  according  to  the  severity  and  distribution  of 
the  lesion.  When  the  nerves  have  been  torn  or  considerably 
damaged  there  would  be  a  combination  of  the  motor  and  sen- 
sory symptoms  detailed  under  diseases  of  the  separate  nerves. 
According  to  the  nerves  involved,  there  would  be  varjang 
degrees  of  atroph}^ ;  DeR ;  trophic  and  vaso-motor  disturb- 
ances; and  if  neuritis  is  the  lesion,  pain  and  tenderness. 
Certain  movements  are  especially  liable  to  be  involved — viz., 
abduction  and  elevation  of  the  arm  (circumflex  and  posterior 
thoracic  nerves)  ;  extension  of  the  arm  (musculo-spiral) ;  flex- 
ion of  the  forearm  upon  the  arm  (musculo-cutaneous).  When 
but  slight  damage  has  been  sustained  the  symptoms  may  con- 
sist of  nothing  more  than  numbness  and  slight  weakness  of 
the  arm,  which  may  disappear  in  a  few  days.  When  due  to 
lesion  within  the  spinal  canal  irritation-symptoms,  as  shoot- 
ing-pains down  the  arm  and  muscular  spasms,  usually  precede 
the  paralysis. 


PRIMARY  BRACHIAL  NEURITIS.  159 

Primary  Brachial  Neuritis, 

Definition — etiology :  The  term  is  used  to  designate  a  pri- 
mary inflammation  of  several  or  all  of  the  nerves  which  enter 
and  make  up  the  brachial  plexus  (Herter). 

It  is  a  rare  disease,  which  occurs  during  the  second  half  of 
life  (after  lifty),  and  is  usually  met  with  in  debilitated  and 
dyspeptic  people,  who  sometimes  in  addition  have  a  history 
of  gout  or  rheumatism.  They  may  previously  have  suifered 
from  neuritis  elsewhere,  most  frequently  in  the  sciatic  nerve. 

The  pathological  process  is  usually  confined  to  the  nerve- 
sheaths  (perineuritis),  and  in  some  cases  is  principally  or 
altogether  confined  to  the  nerve-roots  which  make  up  the 
plexus.     This  is  termed  radicular  neuritis. 

Symptoms :  The  prominent  feature  of  these  cases  is  pain, 
which  is  most  intense.  This  may  begin  at  a  distance  from 
the  plexus,  back  of  the  forearm,  the  wrist,  and  scapular  re- 
gion ;  but  soon  becomes  most  intense  in  the  axilla  and  supra- 
clavicular region,  and  radiates  down  the  arm  in  the  course  of 
the  nerve-trunks.  The  pain  is  dull  aching,  with  sharp,  shoot- 
ing exacerbations,  and  is  aggravated  by  movement.  Hyper- 
algesia is  usually  present  on  the  skin  over  the  plexus.  Less 
frequently  slight  degrees  of  anaesthesia  are  present.  Loss  of 
power  is  not  excessive.  Atrophy  ;  changes  in  the  electrical 
reactions ;  trophic  and  vaso-motor  disturbances,  as  thinned 
and  glossy  skin,  local  oedema,  and  in  old  cases  adhesions  in 
and  swelling  of  the  joints,  are  symptoms. 

Primary  brachial  neuritis — diagnosis :  The  disease  may  be 
confounded  with  neuralgia,  but  the  persistent  tenderness, 
muscular  weakness,  and  atrophy  present  in  neuritis  are  not 
symptoms  of  neuralgia.  Similar  pain  in  the  arm  might  be 
produced  by  aortic  aneurism  ;  but  tenderness  would  not  be 
found,  and  careful  examination  would  cause  discovery  of  the 
aneurism.  The  late  joint-changes  resemble  those  of  rheuma- 
toid arthritis,  but  the  history  of  previous  pain  and  tenderness 
in  the  course  of  the  nerves  would  distinguish  the  neuritis. 
The  symptoms  of  radicular  neuritis  may  be  confounded  with 
those  of  vertebral  disease,  of  meningitis,  or  tumor  in  the  cer- 
vical region.  In  these,  however,  there  would  not  be  nerve- 
tenderness  ;  while  in  bone-disease  there  would  be  tenderness 


160  DISEASES  OF  THE  SPINAL  NERVES. 

on  pressure  and  jarring,  and  muscular  rigidity  ;  and  in  menin- 
gitis or  tumor  there  would  also  be  evidences  of  pressure  upon 
the  cord. 

Prognosis  :  The  affection  is  usually  of  long  duration,  a  year 
or  more.  The  pain  may  continue  after  evidences  of  neuritis 
have  disappeared.  Owing  to  the  changes  in  the  joints,  per- 
inanent  disability  and  deformity  may  result.  Relapses  may 
occur. 

Primary  brachial  neuritis — treatment:  Absolute  rest,  by 
placing  the  arm  upon  a  splint  or  bandaging  it  to  the  side, 
must  be  enjoined.  Cocaine  liypodermically,  beginning  with 
yiQ-th  grain  and  increasing,  will  usually  relieve  the  pain,  but 
must  be  used  cautiously  for  fear  of  provoking  the  habit  (Her- 
ter).  The  general  health  of  the  patient  must  be  built  up. 
Otherwise  the  treatment  is  that  of  neuritis  in  general  (p.  97). 

Brachial  Paralysis  of  the  Upper-arm  Type  (Erb's). 

Etiology — symptoms :  This  form  probably  depends  upon 
injury  to  the  roots  of  the  fifth  and  sixth  cervical  nerves  at 
the  side  of  the  neck  just  in  front  of  the  edge  of  the  trape- 
zius. The  condition  is  not  common,  and  is  met  with  in  in- 
fants, caused  by  traction  on  the  neck  during  birth,  and  is 
then  often  termed  "  obstetrical  paralysis."  In  adults  it  is 
usually  due  to  downward  pressure  on  the  neck,  as  by  carrying 
a  heavy  weight ;  it  may  be  due  to  neuritis  from  other  causes. 

The  paralysis  involves  the  deltoid,  biceps,  brachialis  anti- 
cus,  supinator  longus,  and  supra-  and  infraspinati.  These 
muscles  are  atrophied  and  present  various  degrees  of  DeR. 
Ansesthesia  in  the  areas  supplied  by  the  circumflex  and  mus- 
culo-cutaneous  nerves  is  frequently  found.  Usually  the  mo- 
tor symptoms  are  not  so  pronounced  in  infants  as  in  adults, 
and  sensory  symptoms  are  wanting.  The  prognosis  is  usually 
good. 

Brachial  Paralysis  of  the  Lower-arm  Type. 

Etiology — symptoms :  This  form  is  due  to  involvement  of 
the. seventh  and  eighth  cervical  and  first  dorsal  roots.  When 
the  first  dorsal  root  and  the  communicating  branch  from  the 


BRACHIAL  PARALYSIS  OF  THE  LOWER-ARM  TYPE.   161 

second  dorsal  are  alone  involved,  a  symptom-group  is  pro- 
duced known  as  Khimpke's  paralyHis. 

Neuritis,  eitlier  primary  or  due  to  pressure  from  a  new 
growth  in  the  chest  or  vertebrae,  is  the  usual  cause.  In  the 
first  form  (seventh,  eighth  cervical,  first  dorsal)  there  is  loss 
of  power  in  the  triceps,  pronators  and  flexors  of  the  wrist, 
the  flexors  and  extensors  of  the  fingers,  and  the  muscles  of 
tlie  hand. 

Klumpke's  paralysis  is  characterized  by  atrophy  and  paral- 
ysis of  the  intrinsic  muscles  of  the  hand  and  those  forming 
the  thenar  and  hypothenar  eminences  ;  ansesthesia  in  the  area 
of  ulnar  distribution ;  and  ocular  symptoms,  consisting  of 
myosis  on  the  side  of  the  lesion,  sluggish  contraction  of  the 
pupil,  recession  of  the  eyeball,  and  diminution  in  size  of 
the  palpebral  fissure. 

Combined  paralysis  of  the  brachial  plexus — diagnosis :  The 
nerve  or  nerves  affected  are  determined  by  a  knowledge  of 
the  mode  of  formation,  distribution,  and  functions  of  the 
divisions  of  the  brachial  plexus  already  described.  Mus- 
cular atrophy,  loss  of  reflexes,  clianges  in  the  electrical  reac- 
tions (quantitative  decrease  or  De  li.),  show  that  the  lesion  is 
in  the  peripheral  neuron.  Tlie  presence  of  pain,  tenderness 
over  nerve-trunks,  and  sensory  paralysis  would  indicate  a 
lesion  of  the  nerve-fibres  and  not  of  the  cells  (poKomyelitis). 
The  lesion  is  usually  a  neuritis,  the  cause  of  wliich,  when 
not  due  to  traumatism,  may  at  times  be  difficult  to  determine. 
It  is  then  either  primary  or  secondary  to  some  of  the  patho- 
logical conditions  detailed  under  the  head  of  etiology,  which 
must  be  searched  for.  Primary  neuritis  may  be  confounded 
Avith  neuralgia.  The  distinctive  points  between  the  two  are 
given  on  page  96. 

If  the  nerve  has  been  divided,  rapid  atrophy  and  com- 
]>lete  loss  of  electrical  reactions  will  soon  occur.  Anaesthesia 
in  the  distribution  of  the  nerve  is  also  evident,  but  this  in 
time  may  recover  to  a  greater  or  less  degree. 

Involvement  of  the  nerve-roots  within  the  canal  by  disease 

(tumor,  meningitis,  vertebral  disease)  would  be  distinguished 

from  that  involvement  of  the  nerves  outside  the  canal  by  the 

facts  that  in  the  former,  in  addition  to  atrophy  and  paralysis 

11— N.  D. 


162  DISEASES  OF  THE  SPINAL  NERVES. 

of  the  muscles  of  the  arm  and  hand,  there  would  in  most 
cases  be  a  history  of  muscular  spasms  preceding  the  paral- 
ysis ;  in  some  cases  dissociation  of  sensation,  rigidity  of  the 
neck-muscles,  and  in  the  case  of  vertebral  disease  pain  when 
the  body  is  jarred,  and  evidences  of  impaired  conduction  in 
the  cord.  There  would  be  no  tenderness  over  the  nerve- 
trunks,  as  in  neuritis. 

Cervico-brachial  and  Brachial  Neuralgia. 

Etiology — symptoms :  This  term  is  applied  to  pain  in  the 
distribution  of  the  four  lower  cervical  and  first  dorsal  nerves. 
The  same  causes  that  produce  neuralgia  elsewhere  are  opera- 
tive. Carious  teeth  have  been  given  as  a  cause.  Oppenheim  ^ 
says  that  brachial  neuralgia  is  rarely  due  to  pure  neuralgia, 
but  that  such  patients  may  have  a  commencing  tumor  in  the 
cortical  arm-centres,  commencing  sarcoma  of  the  humerus, 
vascular  spasm,  referred  pains,  angina  pectoris,  gall-stones, 
vertebral  caries,  an  occupation-neurosis,  or,  most  common  of 
all,  neuritis. 

Tender  points,  if  present,  are  found  in  the  axilla,  over  the 
deltoid,  the  level  of  the  elbow,  over  the  ulnar  nerve  at  the 
annular  ligament  of  the  wrist. 

The  prognosis  depends  upon  the  fact  as  to  whether  the 
cause  is  removable  or  not. 

Treatment :  Complete  rest  of  the  arm  is  important.  Other- 
wise it  is  the  same  as  that  employed  for  neuralgia  elsewhere 
(see  Neuralgia  of  Fifth  Nerve). 

DISEASES  OF  THE  DORSAL  NERVES. 
Intercostal  Neuralgia. 

Etiology — symptoms :  Neuralgia  of  the  intercostal  nerves  is 
usually  caused  by  exposure  to  cold  or  to  traumatism,  and 
occurs  spontaneously  in  debilitated  individuals. 

It  is  characterized  by  sharp,  stabbing  pains  shooting  along 
one  or  more  intercostal  spaces,  with  a  constant  ache  in  the 
same  situation  during  the  intervals.  Tender  points  may  be 
found  at  the  points  of  emergence  of  the  nerves  from  the  ver- 
tebrae, in  tlie  axillary  line,  and  at  the  sternocostal  junction. 
^  Quoted  in  Phila.  Med.  Jour.,  vol.  i.  p.  993. 


THE  LUMBAR  AND  SACRAL  PLEXUSES.  163 

Herpes  zoster,  or  shingles,  is  an  aifection  cluiracterized  by 
neuralgic  pains  in  the  course  of  nerves,  uKxst  frequently  of 
the  dorsal  nerves,  and  the  formation  of  groups  of  vesicles 
(herpes)  along  their  course.  As  the  vesicles  form  the  pain 
diminishes  in  intensity.  This  form  is  probably  due  to  in- 
flammation of  a  ganglion  upon  the  corresponding  posterior 
root,  with  secondary  neuritis  of  the  nerve-trunk. 

Mammary  neuralgia  (mastodynia)  is  a  form  of  intercostal 
neuralgia  occurring  in  anaemic,  debilitated  women,  and  is 
characterized  by  neuralgic  pains  in  the  region  of  the  mam- 
mary gland. 

Diagnosis  :  Pain  in  the  course  of  the  intercostal  nerves  may 
be  due  to  cord  disease  (meningo-myelitis,  tumor,  tabes)  or  to 
vertebral  disease.  In  these  cases  the  characteristic  symp- 
toms of  these  aifections  would  soon  develop.  Intercostal 
neuralffia  is  distino-uished  from  rheumatism  of  the  intercostal 
muscles  by  the  fact  that  in  the  latter  the  sharp  shooting  ex- 
acerbations do  not  occur  and  the  pain  is  intensified  by  breath- 
ing. The  acute  stage  of  pleurisy  or  pneumonia  might  also 
be  mistaken  for  it ;  but  in  these  diseases  the  pain  would  be 
much  intensified  by  respiratory  movements  and  by  lying 
upon  the  aifected  side,  and  there  would  be  present  the  physi- 
cal signs  of  the  disorder. 

Prognosis :  Intercostal  neuralgia  is  often  an  affection  in- 
tractable to  treatment.  Herpes  zoster  as  a  rule  recovers  in  a 
few  weeks,  but  may  last  a  long  time. 

Treatment :  In  ordinary  neuralgia  counterirritation  is  of 
benefit.  In  herpes  zoster  dusting-powders  containing  mor- 
phine, camphor,  or  menthol  may  be  applied  to  the  vesicles. 
Otherwise  the  treatment  is  similar  to  that  employed  for  neur- 
algia elsewhere  (p.  86),  excepting  that  in  herpes  zoster  arsenic 
should  not  be  given. 


THE  LUMBAR  AND  SACRAL  PLEXUSES. 

Paralysis  of  the  Nerves  composing  the  Lumbar  Plexus. 

Etiology :  The  lumbar  plexus  is  composed  of  the  first  three 
lumbar  roots  and  one-half  of  the  fourth.  Interference  with  its 
functions  may  be  due  to  the  pressure  of  abdominal  tumors 


164  DISEASES  OF  THE  SPINAL  NERVES. 

(ovarian  tumors,  tuberculosis  of  the  abdominal  lymphatic 
glands),  psoas  abscess,  ascending  neuritis,  and  rarely  a  primary 
neuritis.  The  obturator  and  anterior  crural  have  been  in- 
jured during  parturition,  by  dislocation  of  the  hip,  and 
wounds  or  blows  in  the  groin.  Disease  of  the  vertebree, 
meningitis,  and  tumors  springing  from  the  meninges  and 
meningeal  hemorrhage  may  involve  the  roots  composing  the 
plexus. 

Symptoms :  The  branches  of  the  plexus  are  the  ilio-hypo- 
gastric  and  ilio-inguinal,  arising  from  the  first  lumbar  root ; 
the  genito-crural  from  the  second  and  the  external  cutaneous 
from  the  second  and  third  lumbar  roots ;  the  obturator  and 
anterior  crural  from  the  third  and  fourth  roots.  The  skin  of 
the  lower  part  of  the  abdomen,  up])er  and  inner  part  of  the 
thigh,  scrotum  in  the  male,  labium  in  the  female,  are  supplied 
by  the  ilio-hypogastric  and  ilio-iuguinal.  The  genito-crural 
supplies  the  skin  of  the  anterior  and  upper  part  of  the  thigh 
to  midway  between  the  pelvis  and  knee.  It  also  supplies 
with  motor  fibres  the  cremaster  muscle.  The  skin  of  the 
anterior  and  outer  portions  of  the  thigh  as  far  as  the  knee  is 
supplied  by  the  external  cutaneous. 

Paralysis  of  these  branches  would  cause  anaesthesia  in  the 
respective  areas  supplied  by  them,  and  in  the  case  of  the 
genito-crural  loss  of  the  cremaster  reflex  (Figs.  32  and  33). 

The  obturator  nerve  supplies  the  adductors  of  the  thigh. 
Its  paralysis  would  cause  loss  of  that  function,  evidenced  by 
the  fact  that  the  aifected  leg  cannot  be  put  across  the  other. 
It  usually  suffers  in  company  with  the  anterior  crural. 

The  anterior  crural  nerve  supplies  the  iliacus,  pectineus, 
and  all  the  muscles  of  the  front  of  the  thigh  excepting  the 
tensor  vaginae  femoris.  It  supplies  sensory  fibres  to  the  front 
and  inner  sides  of  the  thigh,  leg,  and  foot  (Figs.  32  and  33). 
Paralysis  of  this  nerve  causes  loss  of  the  knee-jerk  and 
more  or  less  marked  anaesthesia  in  the  area  supplied  by  it. 
The  motor  paralysis  varies  according  to  the  seat  of  the  lesion. 

When  damaged  within  the  pelvis  there  would  be  loss  of 
the  power  of  flexing  the  thigh  upon  the  body  (iliacus)  and 
of  extending  the  leg  upon  the  thigh.  When  the  lesion  is 
lower  down  only  the  power  of  extension  of  the  leg  is  lost. 
Muscular  atrophy  and  change  in  the  electrical  reactions  occur. 


PARALYSIS  OF  NERVES  OF  THE  SACRAL  PLEXUS.   165 

The  superior  (/luteal  nerve  arises  from  the  lumbo-sacral  cord, 
which  is  formed  by  a  union  of  the  fifth  with  a  branch  of  the 
fourth  lumbar  roots.  Its  isolated  paralysis  is  rare.  Abduc- 
tion and  circumduction  of  the  thigh  are  controlled  by  this 
nerve. 

Paralysis  of  the  Nerves  composing-  the  Sacral  Plexus. 

Etiology :  The  sacral  plexus  is  composed  of  the  lumbo- 
sacral cord  and  the  anterior  divisions  of  the  three  upper  and 
part  of  the  fourth  sacral  nerves.  The  plexus  may  be  dam- 
aged by  intrapelvic  growths,  pelvic  inflammations,  by  ver- 
tebral disease,  and  within  the  spinal  canal  by  tumor,  menin- 
gitis, or  meningeal  hemorrhage ;  by  compression  during  partu- 
rition ;  by  ascending  neuritis.  One  of  its  branches,  the  sciatic 
nerve,  is  liable  to  suffer  outside  the  pelvis  from  spontaneous 
neuritis  (sciatica),  and  to  be  injured  by  traumatism,  bone 
disease,  dislocation  of  the  hip,  and  adjacent  morbid  growths. 
The  external  popliteal  (branch  of  the  sciatic)  is  also  liable  to 
suffer  from  various  forms  of  traumatism,  from  pressure,  and 
from  spontaneous  neuritis.  The  posterior  tibial  branch  may 
be  damaged  by  fractures  of  the  leg. 

Paralysis  of  the  nerves  composing  the  sacral  plexus — symp- 
toms :  Paralysis  of  the  small  sciatic  causes  loss  of  power  in 
the  gluteus  maximus,  evidenced  by  interference  with  rising 
from  the  sitting  position.  There  may  also  be  ansesthesia  in 
the  perineum  and  middle  third  of  the  posterior  part  of  the 
thigh  and  upper  half  of  the  calf  (Figs.  32  and  33). 

The  sciatic  nerve  supplies  the  muscles  upon  the  back  part 
of  the  thigh.  Its  branches,  the  internal  and  external  pop- 
liteal, supply  all  the  muscles  below  the  knee. 

A  lesion  near  the  sciatic  notch  would  cause  loss  of  the  power 
of  flexing  the  leg  upon  the  thigh  and  extending  the  thigh, 
and  paralysis  of  all  the  muscles  below  the  knee.  When  the 
lesion  is  below  the  upper  third  of  the  thigh  only  the  muscles 
below  the  knee  are  affected.  Ansesthesia,  if  it  exists,  is 
found  on  the  outer  half  of  the  leg,  most  of  the  dorsum,  and 
all  of  the  sole  of  the  foot  (Figs.  32  and  33). 

The  external  popliteal  or  peroneal  nerve  when  paralyzed, 
causes  loss  of  power  in  the  tibialis  anticus,  extensor  longus 


166  DISEASES  OF  THE  SPINAL  NERVES. 

digitorum,  extensor  brevis  digitorum,  and  peroneal  muscles, 
evidenced  by  loss  of  the  power  of  flexing  the  foot  upon  the 
leg,  and  of  extending  the  first  phalanges  of  the  toes  (foot- 
drop).  If  the  weakness  lasts  any  considerable  time,  over- 
action  of  the  sound  muscles  will  cause  talipes  equinus  to 
develop.  If  anaesthesia  is  present,  it  will  be  found  on  the 
outer  half  of  the  front  of  the  leg  and  most  of  the  dorsum  of 
the  foot  (Figs.  32  and  33). 

The  internal  popliteal  snpplies  the  popliteus,  tibialis  posticus, 
flexor  longus  digitorum,  flexor  longus  poUicis,  and  the  mus- 
cles on  the  sole  of  the  foot.  Its  paralysis  causes  loss  of  the 
power  of  extending  the  foot  upon  the  leg  (plantar  flexion), 
and  if  above  the  origin  of  the  branch  to  the  popliteus  there  is 
loss  of  inward  rotation  of  the  leg  when  flexed.  Ancesthesia 
may  be  found  over  the  outer  part  and  posterior  aspect  of  the 
lower  part  of  the  leg  and  the  sole  of  the  foot  (Figs.  32  and 
33). 

The  external  plantar  nerve:  Paralysis  of  this  nerve  causes 
loss  of  power  in  the  muscles  of  the  little  toe,  the  flexor  ac- 
cessorius,  the  interossei,  the  two  outer  lumbricales,  and  the 
adductor  of  the  big  toe.  The  lumbricales,  interossei,  abduc- 
tor, and  flexor  minimi  digiti  flex  the  first  and  extend  the  sec- 
ond and  third  phalanges  of  the  toes,  an  action  of  importance 
in  the  propulsion  of  the  body  forward  in  walking.  Loss  of 
their  action,  therefore,  is  a  hindrance  in  walking,  as  is  also 
the  deformity  produced  by  the  action  of  their  opponents 
causing  flexion  of  the  second  and  third  phalanges  and  exten- 
sion of  the  first  (similar  to  the  claw-hand  of  ulnar  paralysis). 
Sensory  loss,  if  present,  is  found  in  the  skin  of  the  outer  half 
of  the  sole,  of  the  little  toe,  and  adjacent  half  of  the  fourth 
toe. 

The  internal  plantar  nerve :  This  nerve  supplies  the  short 
flexor  of  the  toes,  the  intrinsic  muscles  of  the  big  toe  except 
the  adductor,  and  the  inner  lumbricales.  In  addition  to  loss 
of  power  of  these  muscles,  angesthesia  may  be  present  on  the 
inner  part  of  the  sole,  the  plantar  surfaces  of  the  three  inner 
toes,  and  the  adjacent  half  of  the  fourth. 

Neuritis  of  the  plantar  nerves  is  thought  to  be  the  cause  of 
the  condition  known  as  erythromelalgia.  This  and  neuritis 
of  the  sciatic  nerve  (sciatica),  and  the  affection  of  the  plantar 


PARALYSIS  OF  THE  SPINAL  NERVES— PROGNOSIS.  167 

nerves  causing  Morton's  disease,  will  receive  separate  considi 
eration. 

Paralysis  of  the  nerves  composing  the  lumbar  and  sacral 
plexuses — diagnosis :  The  diagnosis  of  diseases  of  these  nerves 
depends  upon  the  same  general  principles  that  have  been 
given  for  the  diagnosis  of  lesions  of  the  brachial  plexus  (p. 
161).  In  addition  the  distinction  must  be  made  between  a 
lesion  within  the  spinal  canal  involving  the  cauda  equina  and 
a  lesion  outside  the  canal. 

The  most  common  lesion  which  affects  the  cauda  equina 
is  a  fracture-dislocation  of  a  lumbar  vertebra,  causing  com- 
pression or  crushing  of  the  nerve-roots.  Hemorrhage  mav 
be  an  infrequent  cause  and  also  tumor.  The  symptoms  in 
disease  of  this  region  are  always  bilateral.  In  extra-spinal 
disease,  excepting  in  multiple  neuritis,  they  would  in  most 
cases  be  unilateral.  Both  fracture-dislocation  and  hemor- 
rhage would  be  due  to  traumatism,  and  the  symptoms  would 
be  of  sudden  onset.  The  presence  of  a  neoplasm  w^ould  be 
indicated  by  the  slow  and  progressive  development  of  atrophic 
paralysis,  reflex  disorders  and  anaesthesias  peculiar  to  the  re- 
gion ;  intense  and  increasing  sacral  pain  of  a  radiating  char- 
acter, and  tenderness,  often  very  marked  in  degree,  on  the 
sacrum  (Peterson). 

Paralysis  of  the  spinal  nerves — prognosis :  The  prognosis  in 
paralysis  of  a  spinal  nerve  depends  upon  the  nature  of  the 
cause,  the  length  of  time  it  has  been  in  operation,  the  amount 
of  damage  to  nerve-fibres  that  it  has  inflicted,  the  age  and 
general  health  of  the  patient.  When  the  cause  is  pressure 
exerted  upon  the  nerve,  the  prognosis  is  good  if  that  pressure 
can  be  removed,  even  if  it  has  lasted  as  long  as  a  year.  If 
due  to  a  neuritis,  the  prognosis  depends  considerably  upon  its 
cause ;  if  due  to  infection  or  to  extension  from  a  suppurating 
wound,  the  chances  are  not  so  good  as  if  it  were  due  to  trau- 
matism. The  longer  the  cause  has  been  in  operation,  be  it 
pressure  or  neuritis,  the  worse  the  prognosis.  The  greater 
the  damage  to  the  nerve-fibres,  as  evidenced  by  rapid  and 
marked  development  of  the  symptoms,  the  worse  the  prog- 
nosis. The  electrical  reactions  are  of  assistance  in  determin- 
ing this  point ;  the  more  rapid  and  typical  the  development 


168  DISEASES  OF  THE  SPINAL  NERVES. 

of  DeE,  the  worse  the  prognosis.  Thus  a  rapid  loss  of  fara- 
dic  irritability  and  the  early  development  of  a  complete  DeR 
show  great  damage  to  the  nerve-fibres,  and  it  will  be  months 
before  a  return  of  power  begins ;  but  if  there  is  a  mere 
quantitative  decrease  to  or  no  loss  of  faradic  irritability,  re- 
covery of  power  will  begin  in  a  few  weeks.  When  the  nerve 
has  been  divided,  in  which  case  electrical  irritability  of  the 
muscles  would  rapidly  disappear,  the  prognosis  depends  upon 
the  length  of  time  elapsing  before  the  ends  are  brought  to- 
gether and  sutured.  If  this  is  done  at  once,  motion  usually 
returns  in  two  or  three  months.  Partial  restoration  of  func- 
tion has  occurred  after  a  lapse  of  two  years  before  suturing 
was  performed.  Sensibility  usually  returns  sooner  than  motor 
power.  Its  return  in  cases  of  nerves  that  have  been  divided 
and  sutured  is  of  good  omen.  The  chances  of  complete  and 
rapid  recovery  are  much  better  in  the  young  and  in  those 
whose  general  health  is  good. 

Treatment :  The  method  of  treating  these  cases  when  due 
to  neuritis  has  been  described  on  p.  97.  If  due  to  pressure, 
it  consists  in  the  removal  of  the  cause  if  possible,  and  the 
employment  of  similar  measures  to  promote  the  nutrition  of 
the  muscles  that  have  been  advised  for  the  later  stages  of 
neuritis. 

Neuritis  of  the  Sciatic  Nerve — Sciatica. 

Etiology :  Sciatica  occurs  most  commonly  in  middle  life  or 
after,  in  males  more  than  females,  and  in  those  whose  general 
nutrition  is  impaired.  It  is  also  more  liable  to  occur  in  those 
who  are  subject  to  gout  or  rheumatism,  or  mIio  have  a  family 
history  of  such.  It  sometimes  follows  lumbago.  The  excit- 
ing causes  appear  to  be  exposure  to  cold.  It  seems  esj)ecially 
liable  to  occur  in  those  subjected  to  sudden  and  extreme  alter- 
nations of  temperature.  Traumatism  and  violent  muscular 
exertion  are  also  causes. 

Morbid  anatomy :  The  inflammation  principally  involves 
the  sheath  of  the  nerve,  but  may  extend  to  the  interstitial 
tissue  and  secondarily  involve  the  nerve-fibres  (see  p.  94). 
The  inflammation  is  most  severe  at  the  sciatic  notch  and  the 
middle  of  the  thigh.     The  term  "  sciatica  "  is  also  employed 


SCIATICA.  169 

to  denote  pain  in  the  course  of  the  sciatic  nerve  not  clue  to 
discoveral)le  organic  changes,  a  true  neuralgia. 

Sciatica — symptoms :  The  most  marked  symptom  of  sciatic 
neuritis  is  pain  along  the  course  of  the  nerve,  and  some- 
times along  its  branches  or  in  its  distribution.  Its  onset  mav 
be  sudden,  when  it  often  seems  to  be  excited  by  some  muscu- 
lar movement,  the  pain  rapidly  becoming  very  severe.  In 
the  majority  of  instances  the  onset  is  gradual,  dull  pain  being 
complained  of  about  the  sciatic  notch  or  in  the  back  of  the 
thigh  when  the  leg  is  moved ;  especially  when  moved  in  a 
direction  that  would  make  tension  in  the  nerve  ;  and  by  sit- 
ting on  a  hard  surface,  so  that  pressure  is  made  on  the  nerve. 
This  pain  becomes  more  severe  and  soon  spontaneous  pain  is 
added,  which  is  usually  most  severe  at  the  sciatic  notch  and 
in  the  middle  of  the  thigh.  It  may  also  extend  to  the 
areas  in  which  the  nerve  is  distributed,  and  may  often  be 
felt  in  the  following  points :  (1)  just  above  the  hip-joint, 
below  the  posterior  superior  iliac  spine ;  (2)  in  the  popliteal 
space  ;  (3)  below  the  head  of  the  fibula  ;  (4)  back  of  the  outer 
malleolus  ;  (5)  on  the  dorsum  of  the  foot.  In  character  the 
pain  may  be  burning  or  dull,  associated  with  exacerbations 
of  shooting  pain  down  the  nerve,  and  is  apt  to  be  worse  at 
night.  Tenderness  when  the  nerve  is  pressed  upon  can  usu- 
ally be  found  ;  if  not,  it  can  be  brought  out  by  stretching  the 
nerve — i.  e.,  causing  the  patient  to  lie  upon  his  back  and, 
with  the  leg  fully  extended  at  the  knee-joint,  flexing  it  upon 
the  body. 

Numbness,  tingling,  and  formication  are  often  complained 
of.  Ansesthesia  is  not  found  excepting  in  severe  cases.  As 
the  disease  progresses,  loss  of  power  in  the  muscles  occurs, 
which  become  flabby  and  at  times  considerably  atrophied, 
with  slight  electrical  changes.  If  the  atrophy  is  marked,  de- 
formities due  to  the  unequal  contraction  of  the  muscles  may 
develop.  Trophic  and  vaso-motor  disturbances  may  occur, 
shown  by  a  herpetic  eruption  and  oedema  of  the  leg.  The 
neuritis  may  ascend,  involve  the  lumbar  plexus,  and  cause 
pain,  tenderness,  muscular  weakness  in  the  course,  and  dis- 
tribution of  the  anterior  crural  nerve.  In  rare  instances  the 
inflammation  has  extended  to  the  spinal  cord.  With  rare 
exceptions  the  disease  is  unilateral. 


170  DISEASES  OF  THE  SPINAL  NERVES. 

Sciatica — diagnosis  :  Pain  in  the  conrse  of  the  sciatic  nerve 
may  be  due  to  other  causes.  Rarely  it  may  be  a  pure  neu- 
ralgia. Such  cases  occur  in  those  who  are  debilitated  and 
anaemic  or  who  have  had  neuralgias  elsewhere.  The  char- 
acter of  the  pain  differs,  it  being  spontaneous  from  the  start, 
not  influenced  by  posture  nor  aggravated  by  movement.  It 
is  apt  to  be  referred  to  the  branches  rather  than  to  the  trunk 
of  the  nerve.  Tenderness  along  the  course  of  the  nerve  is 
absent  or  very  slight.  Intrapelvic  disease  has  caused  sciatic 
pain.  In  these  cases  the  slight  tenderness  which  may  be 
present  is  out  of  proportion  to  the  severity  of  the  pain,  while 
a  rectal,  or  if  a  woman  a  vaginal,  examination  may  reveal  the 
cause  of  the  trouble.  Hip-joint  disease  has  also  been  mis- 
taken for  sciatica.  Carejpul  examination,  which  should  be 
made  in  all  cases,  will  always  prevent  this  error.  Vertebral 
disease  and  locomotor  ataxia  may  cause  pain  in  the  course 
of  the  sciatic,  which  under  these  circumstances  would  be  bilat- 
eral, tenderness  over  the  nerve-trunk  would  be  absent,  and 
the  other  symptoms  of  these  disorders  would  be  present. 

The  prognosis  of  primary  sciatica  is  usually  good  as  re- 
gards ultimate  recovery.  The  length  of  time  necessary  for 
this  result  to  be  attained  depends  upon  the  severity  of  the 
symptoms  and  the  ability  of  the  patient  to  undergo  proper 
treatment.  It  may  last  for  months  or  years  and  relapses 
sometimes  occur. 

Sciatica — treatment :  Rest  is  of  the  greatest  importance. 
A  successful  plan  is  that  advocated  by  Graeme  Hammond  : 
the  patient  is  put  to  bed  and  the  leg  immobilized  by  a  long 
hip-splint.  Hot-water  bags  are  kept  along  the  thigh  from 
the  sciatic  notch  to  the  popliteal  space.  The  constant  gal- 
vanic current  is  applied  once  daily  for  five  minutes,  the 
anode  being  placed  under  the  hip  at  the  gluteal  fold  and  the 
cathode  at  the  sole  of  the  foot ;  both  electrodes  should  be 
large.  For  the  acute  pain  at  the  beginning  large  doses  of 
phenacetin  (gr,  15)  are  administered.  In  mild  cases  rest 
in  bed  need  not  be  insisted  upon,  but  the  leg  should  be  kept 
flexed  and  crutches  used  for  walking ;  sitting  upon  hard  or 
cold  surfaces  must  be  avoided.  Ice-bags  sometimes  act  well 
for  the  relief  of  pain,  as  does  also  the  constant  galvanic  cur- 
rent used  as  above  described.     In  cases  of   long  standing 


ERYTHROMELALGIA.  171 

counterirritation  by  the  long-continued  use  of  small  blisters, 
or  better  by  light  burnings  with  the  actual  cautery,  is  of 
service.  Hypodermatic  injections  of  atropine,  distilled  water, 
or  cocaine  may  give  relief.  The  latter  must  be  used  cautiously. 
In  cases  of  rheumatic  origin  the  salicylates  are  indicated. 
Nitroglycerin  may  also  at  times  prove  of  service.  When  all 
else  fails  the  nerve  should  be  cut  down  upon  and  stretched, 
and  if  adhesions  between  the  sheath  and  trunk  are  present 
they  should  be  loosened. 

Constitutional  treatment  must  not  be  neglected,  the  system 
being  built  up  by  appropriate  tonics,  and  if  a  gouty  or  rheu- 
matic patient  the  diet  and  habits  regulated. 

Erythromelalgia. 

Definition — etiology :  This  affection,  first  described  by  S. 
Weir  Mitchell,  affects  the  feet  principally  and  is  characterized 
by  intense  burning  pains  and  redness,  excited  or  aggravated 
when  they  are  allowed  to  hang  down. 

It  is  a  vaso-motor  disturbance.  In  most  instances  it  is 
probably  due  to  a  peripheral  neuritis  of  the  branches  of  the 
plantar  nerves  associated  with  diseased  bloodvessels  (arterio- 
sclerosis) ;  but  cases  have  been  reported  ^  in  which  it  accom- 
panied various  forms  of  spinal  cord  disease. 

Symptoms :  The  pain  comes  on  when  the  patient  attempts 
to  walk  or  the  feet  are  allowed  to  hang  down  ;  the  affected 
part  then  becomes  swollen  and  intensely  congested,  becoming 
a  bright  scarlet  hue.  Profuse  perspiration  of  the  parts  may 
occur.  The  pain  is  of  an  intense  burning  character.  Walk- 
ing may  become  impossible.  Blisters  and  ulcerations  may 
occur,  and  the  symptoms  become  worse  in  warm  weather. 

The  diagnosis  must  be  made  from  Raynaud's  disease  and 
the  pain  caused  by  flat  foot  and  Morton's  disease.  In  Ray- 
naud's disease  the  congestion  is  confined  to  the  fingers,  toes, 
tip  of  ear  or  nose,  etc.;  is  dark  in  color  (venons),  and  is  suc- 
ceeded by  extreme  pallor  and  coldness.  Morton's  disease  is 
discussed  below. 

The  prognosis  as  to  relief  is  bad. 

Treatment :  Elevation  of  the  foot  gives  relief.  Prolonged 
1  Lancet,  Aug.  13,  1898. 


172  DISEASES  OF  THE  SPINAL  NERVES. 

rest  in  bed,  with  tonics,  has  relieved  in  some  cases.  S.  Weir 
Mitchell  has  suggested  resection  of  the  long  saphenous  and 
musculo-cutaneous  nerves  and  stretching  of  the  plantar 
nerves,  which  was  successful  in  one  case. 

Metatarsal  Neuralg-ia,  or  Morton's  Disease. 

This  term  has  been  applied  to  a  condition  characterized  by 
severe  pain,  excited  by  walking  or  standing,  which  usually 
starts  at  the  base  of  the  fourth  toe,  soon  involves  the  entire 
foot,  and  frequently  extends  up  the  leg.  It  is  either  throb- 
bing, lancinating,  or  both  combined.  Pain  is  excited  by 
pressure  over  the  head  of  the  third  and  fourth  metatarsal 
bones  and  sometimes  by  pressing  the  metatarsal  bones  to- 
gether. It  is  caused  by  a  neuritis  due  to  pressure  of  the 
metatarsal  bones  upon  the  branches  of  the  plantar  nerves. 
Talipes  planus,  or  flat  foot,  is  frequently  associated. 

The  treatment  consists,  if  flat  foot  is  })resent,  in  the  relief 
of  that  condition  by  proper  mechanical  means  (plantar 
springs,  etc.)  and  strengthening  of  the  muscles  of  the  leg 
and  foot  by  exercise,  massage,  and  electricity.  If  these 
measures  fail,  excision  of  the  head  of  the  metatarsal  bone, 
where  the  pain  is  located,  should  be  performed. 

Neuralgia  of  the  Lumbar  Plexus. 

When  neuralgic  pains  affect  the  lower  half  of  the  trunk 
they  are  termed  lumbo-abdominal  neuralgia.  Painful  points 
may  be  found  near  the  middle  of  the  iliac  crest  and  at  the 
lower  part  of  the  rectus  muscle.  Care  must  be  taken  not  to 
confound  the  affection  with  the  pain  due  to  abdominal  or 
intrapelvic  disease  and  rheumatism  of  the  muscles. 


CHAPTER    IX. 

INFLAMMATION  OF  THE  MENINGES. 

The  dura  mater  is  composed  of  two  layers  :  the  inner  layer 
is  thin  and  has  a  smooth  surface  covered  with  endothelium  ; 
the  outer  layer  is  thicker  and  serves  as  a  periosteum  for  the 
bones.  Either  of  these  layers  may  be  aifected  by  inflamma- 
tion. Inflammation  of  the  dura  mater  is  termed  pachymen- 
ingitis, either  external  or  internal,  according  to  the  layer 
affected. 

EXTERNAL  CEREBRAL  PACHYMENINGITIS. 

Etiology :  The  usual  causes  are  traumatisms  of  various 
kinds  to  the  head,  sunstroke,  caries  of  the  cranial  bones  due 
to  syphilis,  middle  ear  disease  or  ozsena,  and  secondary  in- 
fection due  to  inflammation  of  the  surface,  as  erysipelas  of 
the  head  or  face.     Sometimes  no  cause  can  be  traced. 

Morbid  anatomy :  In  acute  cases  there  are  at  first  redness 
and  oedematous  swelling  of  the  tissues,  with  later  the  forma- 
tion of  pus,  which  accumulates  between  the  dura  and  tlie 
bone.  In  the  more  chronic  forms  there  is  thickening  of  the 
membrane,  which  is  more  or  less  firmly  attached  to  the  bone 
and  pia  arachnoid.  Osteophytes  may  be  formed  upon  the 
surface  of  the  bones  and  in  the  dura  (ossifying  pachymenin- 
gitis).    The  disease  may  extend  to  the  pia  and  cord. 

The  symptoms  are  indefinite,  the  diagnosis  often  depending 
upon  the  discovery  of  the  cause.  They  consist  of  severe 
headache,  vertigo,  delirium,  and  sometimes  convulsions ; 
fever  may  or  may  not  be  present.  It  should  be  remembered 
that  similar  symptoms  often  precede  the  infectious  diseases. 
If  a  collection  of  pus  is  formed  which  makes  pressure  upon 
the  motor  cortex,  there  may  be  more  or  less  pronounced 
paralysis  upon  the  opposite  side. 

Prognosis :  The  acute  form  is  serious ;  the  chronic  variety, 

173 


174  INFLAMMATION  OF  THE  MENINGES. 

while    rebellious   to   treatment,  need   not   necessarily   cause 
death. 

Treatment :  At  the  outset  antiphlogistic  measures,  as  pur- 
gatives, cold  to  the  head,  wet  cups  at  the  back  of  the  neck, 
and  ergot,  bromides,  and  mercurials  internally,  should  be  em- 
ployed. If  there  is  reason  to  suspect  fracture  or  the  presence 
of  pus,  trephining  is  indicated.  In  the  chronic  forms  the 
use  of  potassium  iodide  and  mercury,  in  full  doses  if  syph- 
ilis is  suspected,  is  indicated ;  and  vigorous  and  prolonged 
counterirritation  at  the  back  of  the  neck,  preferably  by 
lightly  burning  with  the  actual  cautery.  If  these  measures 
fail,  the  removal  of  a  button  or  two  of  bone  with  the  trephine 
may  give  relief. 

EXTERNAL  SPINAL  PACHYMENINGITIS. 

Etiology :  The  most  common  caxise  is  tubercular  caries  of 
the  vertebrae.  It  is  a  secondary  involvement  of  the  mem- 
branes by  the  infectious  process.  Other  causes  are  bone  dis- 
ease due  to  syphilis,  pressure  by  tumor  or  aneurism,  trauma, 
exposure,  infection  from  suppurative  inflammation  in  the  neigh- 
borhood of  the  vertebrae,  and  syphilis  without  disease  of 
bones.     Alcoholism  is  a  predisposing  cause. 

Morbid  anatomy :  In  that  due  to  vertebral  caries,  the  usual 
cause,  the  membrane  at  the  seat  of  disease  is  thickened  and 
covered  with  a  layer  of  caseous  material,  which  may  sur- 
round the  entire  membrane  or  be  confined  to  the  ventral  sur- 
face. In  time  fibrous  tissue  forms,  and  the  cellular  tissue 
outside  the  dura  is  infiltrated  with  pus.  In  chronic  cases  the 
cord  may  also  become  affected  (meningo-myelitis). 

The  symptoms  are  first  those  of  irritation  of  the  motor  and 
sensory  roots,  evidenced  by  radiating  pains  in  their  course ; 
pain  in  the  back,  hyperaesthesia,  muscular  twitchings,  and 
rigidity.  Later  they  and  the  spinal  cord  become  compressed, 
and  paralytic  symptoms  appear,  consisting  of  paraplegia,  ex- 
aggeration of  the  reflexes  governed  by  that  part  of  the  cord 
which  is  below  the  seat  of  the  lesion,  and  in  severe  cases  in- 
volvement of  the  sphincters  and  anaesthesia.  This  last  may 
rarely  take  the  form  of  the  dissociation  of  sensation,  loss  of 
pain  and  temperature,  and  preservation  of  the  tactile  sense. 


INTERNAL   CEREBRAL  PACHYMENINGITIS.         175 

The  diagnosis  depends  on  the  history  of  symptoms  of  irri- 
tation of  the  motor  and  sensory  nerve-roots,  followed  by 
paralysis  and  interference  with  the  functions  of  the  cord. 
Evidences  of  vertebral  bone-disease  should  always  be  sought 
for,  which  is  evidenced  by  the  presence  of  kyphosis,  local 
pain,  tenderness  on  jarring,  etc. 

The  prognosis  is  serious,  but  complete  or  partial  recovery 
may  take  place  after  a  long  period  of  time. 

The  treatment  in  cases  due  to  bone  disease  is  that  of  verte- 
bral caries  :  rest,  extension,  and  plaster  jackets ;  if  after  a 
thorough  trial  these  fail,  laminectomy  may  be  done ;  inter- 
nally, antisyphilitic  medication,  if  due  to  syphilis ;  cod-liver 
oil  and  other  tonics,  if  due  to  tuberculosis.  In  cases  due  to 
other  causes  complete  rest  and  counterirritation  to  the  spine 
(blister  or  cautery)  are  indicated.  Bedsores  must  be  guarded 
against  and  symptoms  treated  as  they  arise. 

INTERNAL  CEREBRAL  PACHYMENINGITIS. 

Etiology :  The  inner  layer  of  the  dura  mater  is  much  less 
frequently  diseased  than  the  outer.  It  may  be  met  with  in 
two  forms — purulent  and  hemorrhagic.  In  the  purulent  form 
it  may  be  inflamed  in  company  with  the  outer  layer  as  a  con- 
sequence of  trauma,  or  a  purulent  inflammation  of  the  pia 
may  extend  to  it.^  The  latter  form,  known  as  hemorrhagic 
internal  pachymeningitis,  or  hsematoma  of  the  dura  mater, 
while  rare,  is  more  common  than  the  purulent  meningitis. 
This  condition  is  met  with  chiefly  in  males,  and  is  a  disease 
of  old  age.  According  to  Gowers,  more  than  half  the 
cases  occur  in  persons  over  fifty,  25  per  cent,  of  these  oc- 
curring after  seventy.  It  is  most  frequently  found  in  cases 
of  chronic  insanity  and  in  those  who  have  been  the  victims 
of  chronic  alcoholism.  It  may  occur  in  cases  of  profound 
anaemia  and  diseases  of  the  blood  and  bloodvessels.  It  has 
also  been  found  in  rachitic  and  ill-nourished  babies.^ 

The  symptoms  of  either  form  are  indefinite.     Those  of  the 

*  Leszynsky  has  recently  reported  a  case  of  inflammation  (purulent)  prac- 
tically limited  to  the  internal  layer,  due  to  middle  ear  disease. 

^  See  Herter  on  Hemorrhagic  Internal  Pachymeningitis  in  Children. 
American  .Journal  of  Medical  Sciences,  August,  1898,  p.  292. 


176  INFLAMMATION   OF  THE  MENINGES. 

purulent  form  are  those  of  the  form  of  inflammation  of  the 
external  layer  or  pia  that  it  accompanies. 

In  the  hemorrhagic  form  no  symptoms  may  be  noticed,  or 
the  patient  may  have  at  varying  intervals  apoplectic  attacks, 
the  symptoms  of  which  are  of  brief  duration.  These  are 
slowness  and  irregularity  of  the  pulse,  contracted  pupils 
with  poor  or  no  response  to  light,  vomiting,  and  coma. 
With  these  there  may  be  more  or  less  complete  paralysis  of 
a  hemiplegic  form.  In  some  cases  severe  headache,  vertical 
or  temporal,  may  be  a  prominent  symptom. 

The  morbid  anatomy  of  the  hemorrhagic  form  presents  one 
of  three  conditions  :  (1)  a  delicate  subdural  vascular  mem- 
brane, formed  by  the  penetration  of  bloodvessels  and  granu- 
lation-tissue into  an  inflammatory  exudate ;  (2)  simple  sub- 
dural hemorrhage ;  (3)  a  vascular  membrane  with  the  blood- 
clot.  Cysts  may  occur  within  the  membrane.  The  source 
of  the  hemorrhage  is  probably  the  bloodvessels  of  the  dura. 
Atrophy  of  the  convolutions  is  usually  associated  with  the 
hemorrhage. 

Diagnosis  :  The  condition  may  be  expected  to  exist  when 
symptoms  such  as  have  been  described  occur  in  alcoholics  or 
cases  of  chronic  insanity,  especially  terminal  or  senile  de- 
mentia or  paresis. 

The  prognosis  is  bad,  a  fatal  result  being  almost  certain  to 
occur  in  time. 

Treatment :  During  the  attack  the  head  should  be  elevated, 
with  the  application  of  cold  and  the  administration  of  purga- 
tives. If  possible,  the  cause,  as  excessive  use  of  alcohol, 
should  be  removed. 


INTERNAL  SPINAL  PACHYMENINGITIS. 

Etiology  :  This  may  be  associated  with  external  pachymen- 
ingitis due  to  vertebral  caries  or  syphilis.  There  is,  more- 
over, a  special  form  similar  to  cerebral  hemorrhagic  pachy- 
meningitis. In  most  cases  this  involves  the  cervical  region, 
and  is  known  as  hypertrophic  cervical  pachymeningitis. 
Alcoholism,  exposure,  and  trauma,  the  last  being  the  most 
frequent,  are  causes. 

The  first  symptoms  are  pains  of  a   neuralgic  character  in 


INTERNAL  SPINAL  PACHYMENINGITIS.  177 

the  occiput,  neck,  and  shoulders,  radiating  down  the  arms. 
With  these  may  be  associated  twitchings  of  the  arm-rauscles. 
Atrophy  and  paralysis,  beginning  in  the  thenar,  hypothenar, 
and  interosseous  muscles,  soon  follow.  These  spread  to  the 
muscles  of  the  shoulder  and  arm.  The  paralysis  is  usually  flac- 
cid, but  there  may  be  rigidity.  Fibrillary  tremors  are  present. 
Stiffness  and  scoliosis  of  the  cervical  spine  occur.  As  the 
disease  progresses,  owing  to  secondary  degeneration  occur- 
ring in  the  cord,  sj)astic  paraplegia,  without  atrophy  and 
with  increased  reflexes,  and  with  or  without  paralysis  of  the 
bladder  and  rectum,  makes  its  appearance.  The  sensory 
changes  vary  in  type.  The  so-called  dissociation  of  sensa- 
tion may  be  present  in  some  areas.  In  others  there  may  be 
tactile  anesthesia  or  merely  delayed  sensation.  They  may 
have  a  paraplegic  or  a  hemiplegic  distribution.  Owing  to 
involvement  of  the  cervical  sympathetic,  pupillary  changes 
may  occur. 

The  morbid  anatomy  is  identical  with  that  of  hemorrhagic 
cerebral  pachymeningitis,  consisting  of  successive  hemor- 
rhages upon  the  surface  of  the  dura,  followed  by  the  forma- 
tion of  fibrous  tissue,  until  the  cord  is  fiually  surrounded  and 
compressed  by  a  dense  mass  of  connective  tissue.  In  syphi- 
litic cases  a  gummatous  mass  may  be  the  cause  of  the  similar 
symptoms. 

The  diagnosis  must  be  made  from  syringomyelia,  vertebral 
caries,  tumor,  amyotrophic  lateral  sclerosis,  and  primary  bra- 
chial neuritis.  When  the  dissociation  of  sensation  is  present, 
the  diagnosis  from  syringomyelia  is  difficult ;  the  occurrence 
of  pain  or  a  history  of  syphilis  would  point  to  pachymenin- 
gitis. Meningitis  due  to  vertebral  caries  would  be  associated 
with  tenderness  upon  pressure  or  jarring  the  body,  and  other 
evidences  of  bone  disease.  In  tumor  the  symptoms  would 
probably  be  more  gradual  and  irregular  in  their  progress,  and 
deformity  of  the  neck  would  not  develop.  In  amyotrophic 
lateral  sclerosis  there  is  no  severe  pain,  if  any,  nor  anaesthe- 
sia, and  the  atrophy  involves  the  muscles  of  the  legs.  In  pro- 
gressive muscular  atrophy,  a  similar  distribution  of  atrophy, 
with  knee-jerk  absent  or  not  increased,  and  no  sensory  changes 
would  occur.  Primary  brachial  neuritis  (the  nidicular  form) 
is  not  associated  with  cord  symptoms ;  neither  would  there  be 
12— N.  D. 


178  INFLAMMATION  OF  THE  MENINGES. 

deformity.  The  atrophy  would  be  unilateral  and  not  so  pro- 
nounced. It  is  more  apt  to  occur  in  women  ;  pachymen- 
ingitis is  more  common  in  men.  If  the  process  occurs  in  the 
lumbar  region,  as  it  rarely  does,  there  are  shooting-pains 
down  the  legs  and  absent  knee-jerks,  resembling  somewhat 
both  locomotor  ataxia  and  multiple  neuritis,  but  differing 
from  the  former  by  the  presence  of  muscular  atrophy  and 
paralysis ;  and  from  the  latter  by  the  absence  of  tenderness 
over  the  nerve-trunks  and  the  presence  of  evidences  of  cord- 
involvement. 

As  regards  cure,  the  prognosis  is  bad  ;  but  life  may  be  pre- 
served for  years. 

The  treatment  consists  of  rest ;  counterirritation  by  the 
cautery  or  blister ;  and  iodide  of  potassium  and  bichloride  of 
mercury  internally.  Bedsores  must  be  guarded  against ;  and 
if  paralysis  of  the  bladder  exists,  the  catheter  used  and  the 
occurrence  of  cystitis  avoided  if  possible. 

LEPTOMENINGITIS— VARIETIES. 

Inflammation  of  the  cerebral  pia  mater,  or  leptomeningitis, 
occurs  as  one  of  the  following  types  :  (1)  Simple,  due  to 
either  the  pneumococcus,  streptococcus,  and  staphylococcus,  or 
typhoid  bacillus  ;  and  those  of  other  infectious  diseases,  gono- 
coccus,  or  colon-bacillus.  The  first  two  are  the  most  common. 
(2)  Epidemie  cerebrospinal,  due  to  the  diplococcus  intracellu- 
laris  meningitidis.  (3)  Tubercular,  caused  by  the  tubercle 
bacillus.  (4)  Serous  meningitis.  (5)  Sypkilitio  meningitis. 
These  forms  may  be  acute  or  chronic,  usually  the  former ; 
the  latter  when  it  occurs  being  a  sequel  of  the  acute. 

ACUTE  SIMPLE  CEREBRAL  MENINGITIS. 

Etiology :  It  may  occur  as  a  sequel  or  accompaniment  of 
septicsemia  or  pyaemia,  and  of  one  of  the  infectious  diseases. 
Pneumonia  is  the  disease  in  which  this  most  frequently  occurs. 
Meningitis  may  also  sporadically  be  caused  by  the  micro-or- 
ganism of  pneumonia  (the  pneumococcus  pneumoniae)  inde- 
pendently of  the  existence  of  pneumonia ;  by  diseases  of  the 
frontal  sinuses  and  upper  nasal  passages ;  or  a  brain-abscess 
may  reach  the  surface  and  cause  a  meningitis.     It  may  be 


ACUTE  SIMPLE  CEREBRAL  MENINGITIS.  179 

due  to  disease  or  injury  of  the  cranial  bones,  and,  what  is  the 
most  frequent  cause  of  all,  infection  from  disease  of  the  mid- 
dle-eai'  and  mastoid  cells.  Alcoholism,  chronic  nephritis,  arte- 
rio-sclerosis,  gout,  and  the  wasting  diseases  of  children  are 
predisposing  causes.  The  disease  occurs  most  frequently  in 
males  and  in  the  young. 

Acute  simple  cerebral  meningitis — symptoms :  As  the  inflam- 
mation may  be  confined  to  the  vertex  or  the  base,  or  to  lim- 
ited areas  in  these  localities,  and  also  may  or  may  not  be 
attended  with  the  presence  of  pus,  it  will  be  understood  that 
while  there  will  be  certain  symptoms  common  to  all  these 
forms,  there  will  be  special  symptoms  dependent  upon  the 
location  and  character  of  the  inflammatory  process. 

In  all  forms  there  is  usually  a  short  prodromal  period,  in 
which  the  patient  suffers  from  malaise,  languor,  irritability, 
headache,  loss  of  appetite,  vomiting,  and  vertigo.  This 
period  may  be  absent,  the  attack  being  ushered  in  suddenly 
by  a  chill.  These  are  succeeded  by  an  irritative  stage  in 
which  the  symptoms  consist  of  fever ;  violent  and  constant 
headache ;  delirium  ;  hypersesthesia  of  the  skin  and  special 
senses ;  vomiting,  independent  of  the  presence  of  food  in  the 
stomach ;  contracted  and  perhaps  unequal  pupils ;  rigidity 
of  the  muscles  of  the  neck  ;  retraction  of  the  head ;  and 
retraction  of  the  abdominal  muscles,  forming  the  so-called 
boat-shaped  abdomen.  In  some  cases  a  general  rigidity  may 
be  present.  According  to  Kernig,  a  symptom  found  in  all 
cases  of  leptomeningitis  is  inability  of  the  patient  fully  to  ex- 
tend the  legs  when  sitting  up,  while  there  is  ability  to  do  so 
when  recumbent.  If  such  a  patient  is  made  to  rise  from  the 
recumbent  to  the  sitting  position  and  an  attempt  made  to  ex- 
tend the  leg  on  the  thigh,  there  is  contraction  of  the  flexors, 
which  prevents  the  leg  being  extended.  The  same  phenom- 
enon is  seen  if,  while  recumbent,  the  thigh  is  flexed  on  the 
abdomen  and  an  attempt  is  made  to  extend  the  leg  on  the 
thigh.  When  the  patient  is  recumbent  and  the  thigh  ex- 
tended, the  leg  can  also  be  extended. 

Muscular  twitchings  or  convulsions  take  place.  Drawing 
a  dull  point  along  the  skin  causes  a  red  line  to  appear  (tache 
c^rebrale).  The  tongue  is  heavily  furred,  and  there  are  obsti- 
nate coListipatioii  and  scanty  tiiid  ])erhaps  albuminous  urine. 


180  INFLAMMATION  OF  THE  MENINGES. 

Optic  neuritis  may  or  may  not  occur.  The  pulse  is  apt  to  be 
irregular,  and  may  be  slow — 50  to  70.  As  the  disease  pro- 
gresses the  paralytic  stage  sets  in,  and  muscular  paralyses 
succeed  the  twitchings  and  convulsions.  The  patient  becomes 
stupid,  and  finally  comatose,  the  pupils  dilate,  the  respiration 
becomes  of  the  Cheyne-Stokes  type,  the  skin  becomes  clammy, 
and  involuntary  evacuations  of  urine  and  fseces  take  place. 
When  the  disease  is  limited  to  the  vertex  delirium,  headache, 
and  convulsions  are  more  marked  than  in  basal  meningitis ; 
and  when  paralysis  occurs  it  is  likely  to  be  that  of  either  an 
entire  limb  or  of  a  hemiplegic  type.  Optic  neuritis  and  rigid- 
ity of  the  neck-muscles  are  not  so  likely  to  be  present.  In 
meningitis  of  the  base,  paralyses  of  various  cranial  nerves 
occur ;  optic  neuritis,  rigidity  of  the  neck,  occipital  headache, 
and  vomiting  are  liable  to  be  marked.  A  hemiparesis  due 
to  pressure  upon  the  crus  may  be  a  symptom  also. 

Meningitis  confined  to  limited  areas  may  be  determined 
by  the  headache  being  limited  to  a  small  area  of  the  head, 
and  by  focal  symptoms,  as  disturbances  of  certain  motor 
centres. 

"When  the  meningitis  is  due  to  purulent  infection  chills 
occur,  succeeded  by  high  temperature,  and  the  course  is  apt 
to  be  very  rapid. 

Morbid  anatomy :  The  pia  arachnoid  is  either  thickened 
and  congested  or  infiltrated  with  yellowish  purulent  exuda- 
tion, which  is  more  pronounced  along  the  course  of  the  veins. 
The  ependyma  may  be  granular  and  thickened,  and  the  ven- 
tricles dilated  and  filled  with  turbid  fluid  or  lymph.  The 
cortex  may  be  softened  and  foci  of  hemorrhage  and  enceph- 
alitis may  be  found. 

Diagnosis :  There  should  usually  be  no  difficulty  in  deter- 
mining that  meningitis  is  present  when  one  of  the  exciting 
causes  mentioned  is  followed  by  symptoms  such  as  have  been 
detailed  above. 

Meningitis  of  this  type  may  be  confounded  with  abscess, 
and,  as  both  may  be  produced  by  similar  causes,  they  may 
coexist.  The  explosive  manifestations  after  the  disease  has 
been  for  a  long  time  latent  (see  Brain  Abscess)  are  charac- 
teristic of  abscess.  Unilateral  symptoms  are  more  common 
in  abscess ;  exaggerated  deep  reflexes  upon  one  side  may  be 


CEREBROSPINAL  MENINGITIS.  181 

found.  Subnormal  pulse  and  temperature  point  to  al)scess. 
The  cranial  nerves  at  the  base  are  more  apt  to  be  involved  iu 
meningitis  than  in  abscess. 

The  symptoms  of  urscmia  may  rest'nd)le  those  of  men- 
ingitis; an  examination  of  the  urine,  the  presence  of  cedema, 
the  age  and  appearance  of  the  patient,  and  the  presence  of 
albuminuric  neuro-retinitis  would  enable  us  to  settle  the 
question. 

Care  must  be  taken  not  to  mistake  the  delirium  which 
accompanies  typhoid  and  other  fevers  for  meningitis. 

Acute  delirium  or  typhomania  may  be  mistaken  for  men- 
ingitis. In  this,  optic  neuritis,  focal  paralytic  symptoms, 
muscular  rigidity,  hypersesthesia,  and  convulsions  do  not 
occur. 

The  distinctive  features  of  serous,  tubercular,  epidemic 
cerebro-spinal,  and  syphilitic  meningitis  will  be  mentioned 
when  these  forms  are  described. 

The  prognosis  is  very  grave. 

Acute  simple  cerebral  meningitis — treatment :  The  patient 
must  be  kept  quiet  in  a  darkened  room.  A  calomel  purge, 
followed  by  small  doses  of  iodide  of  potassium,  is  given. 
An  ice-bag  should  be  applied  to  the  head,  and  in  robust 
adults  blood  may  be  abstracted  by  means  of  leeches  or  wet  cups 
applied  to  the  back  of  the  neck  or  temples.  The  internal  use 
of  iodoform,  gr.  vj-xij  daily,  has  been  recommended.  Favor- 
able results  have  been  reported  from  the  use  of  inunctions  of 
the  shaved  scalp  with  a  10  per  cent,  ointment  of  iodoform 
used  conjointly  with  the  above  measures.  Pain  must  be  con- 
trolled by  phenacetin  or  similar  drugs,  and  if  these  fail  by 
opium.  In  meningitis  due  to  pus-infection  surgical  measures 
(trephining)  may  be  required. 

EPIDEMIC   CEREBRO-SPINAL   MENINGITIS,  OR    SPOTTED 

FEVER. 

Definition  and  etiology:  A  specific  infectious  disease,  occur- 
ring sporadically  and  in  epidemics,  caused  by  the  diplococcus 
intracellularis  and  characterized  by  inflammation  of  the 
cerebro-spinal  membranes  and  a  clinical  course  of  great 
irregularity  (Osier). 


182  INFLAMMATION  OF  THE  MENINGES. 

Children  are  more  liable  than  adults.  It  especially  occurs 
in  cold  or  temperate  climates.  It  is  most  apt  to  attack  those 
living  in  barracks  or  crowded  houses. 

Symptoms :  Malignant  types  occur  during  epidemics  in 
which  the  patient  is  suddenly  seized  with  chills,  fever,  head- 
ache, somnolence,  and  muscular  spasms.  The  pulse  soon 
becomes  feeble  and  slow,  and  a  purpuric  rash  appears,  death 
occurring  in  a  few  hours. 

In  most  cases  the  symptoms  are  similar  to  those  of  simple 
meningitis,  with  the  addition  of  pains  in  the  back  and  limbs 
and  the  occurrence  in  most  cases  of  a  petechial  rash ;  urti- 
carial or  erythematous  eruptions  may  also  appear.  Leuko- 
cytosis also  occurs.  At  the  onset  the  pulse  is  full,  strong, 
and  slow.  The  elevation  of  temperature  may  be  slight  or 
pronounced.  Either  pleurisy,  pericarditis,  parotitis,  pneu- 
monia, or  arthritis  may  occur  as  complications. 

Epidemic  cerebro-spinal  meningitis — morbid  anatomy :  In 
malignant  cases  no  changes  in  the  membranes  can  be  noticed, 
but  only  extreme  congestion,  since  death  occurs  before  the 
characteristic  lesions  have  time  to  develop.  In  ordinary 
forms  the  appearances  are  those  of  simple  meningitis  plus 
involvement  of  the  spinal  membranes.  The  diplococcus  in- 
tracellularis  is  found  in  the  exudate. 

Diagnosis :  In  sporadic  cases  the  diagnosis  may  be  difficult. 
Typhoid  fever  and  pneumonia  and  other  febrile  diseases  may 
present  somewhat  similar  symptoms.  It  may  be  still  more 
difficult  to  distinguish  it  from  other  forms  of  meningitis. 
The  most  reliable  test  is  the  lumbar  puncture,  which  is 
performed  by  introducing  an  ordinary  sterilized  exploring- 
needle  between  the  second  and  third  or  third  and  fourth  lum- 
bar vertebrse.  At  a  depth  of  4  cm.  in  children  and  7  to  8 
cm.  in  adults,  fluid  comes  through  the  needle,  5  to  10  c.c.  of 
which  should  be  caught  in  a  sterilized  test-tube  and  studies 
made  to  determine  the  presence  or  not  of  the  diplococcus.^ 
The  fluid  obtained  may  be  clear,  turbid,  or  purulent.  It  is 
usually  turbid  when  meningitis  is  present,  but  may  be  clear. 
These  conditions  may  alternate  at  successive  punctures. 

^  A  case  has  recently  been  reported  by  Gwyn  in  wbich  the  diplococcus 
was  found  in  the  blood  and  also  in  the  fluid  from  one  knee-joint.  Phila. 
Med.  Jour.,  vol.  ii.  p.  1255. 


TUBERCULAR  MENINGITIS.  183 

The  prognosis  is  grave,  the  mortality  ranging  in  different 
epidemics  from  20  to  75  per  cent.  The  outlook  is  worse  in 
children,  and  in  cases  having  high  fever,  frequent  convul- 
sions, and  deep  coma.  Cases  of  protracted  duration  do  not 
often  recover. 

Epidemic  cerebro-spinal  meningitis — treatment :  This  con- 
sists of  cold  to  the  head  and  spine,  bloodletting  in  the  robust, 
cold  packs  or  baths  if  the  temperature  is  high.  Stille  recom- 
mends administering  a  grain  of  opium  every  hour  in  severe 
cases,  or  every  two  hours  in  milder  ones.  Potassium  iodide 
has  been  advocated  by  some.  The  diet  must  be  liquid  and 
nutritious.  Feeding  by  means  of  a  tube  introduced  into  the 
stomach  may  be  necessary.  Alcoholic  stimulants  must  be 
given  when  the  heart  begins  to  fail. 


TUBERCULAR  MENINGITIS. 

Etiology :  This  affection,  also  known  as  acute  hydrocephalus, 
is  an  infection  of  the  meninges  by  the  tubercle  bacillus.  It 
may  occur  at  any  age,  but  attacks  children  more  often  than 
adults,  usually  between  the  second  and  fifth  years.  A  pri- 
mary focus  to  tuberculous  disease  can  usually  be  found,  most 
often  in  the  bronchial  or  mesenteric  glands.  The  eruptive 
fevers,  especially  measles,  and  traumatism  to  the  head  some- 
times seem  to  act  as  exciting  causes.  While  the  reverse  is 
much  more  common,  the  process  may  extend  from  the  spinal 
to  the  cerebral  meninges. 

Symptoms  :  Prodromes  are  most  common  and  of  long  dura- 
tion (several  weeks)  in  this  form  of  meningitis.  The  patient 
loses  flesh  and  is  restless  and  irritable.  The  symptoms  point- 
ing to  meningeal  trouble  may  appear  suddenly  with  convul- 
sions ;  but  more  frequently  the  first  symptoms  are  headache, 
fever,  and  vomiting,  which  are  followed  by  the  other  symp- 
toms of  meningitis  (basilar  form)  already  described.  In  the 
paralytic  stage  the  temperature  may  become  subnormal. 
Leukocytosis  may  also  occur.  Skene's  sign,  when  present,  is 
of  diagnostic  value.  It  is  dependent  upon  the  deposition  of 
tubercles  around  the  pupillary  margin  of  the  iris,  which  ap- 
pears as  a  white  wreath ;  in  a  few  days  a  yellowish-brown 


184  INFLAMMATION  OF  THE  MENINGES. 

circle  takes  its  place,  which  gradually  disappears  as  the  dila- 
tation of  the  pupil  common  to  the  later  stages  takes  place. 

Tubercular  meningitis — morbid  anatomy :  The  arachnoid 
and  pia  at  the  base  are  mainly  involved,  the  neighborhood 
of  the  Sylvian  fissure,  optic  chiasm,  and  interpeduncular 
space  being  most  markedly  so.  The  membranes  may  be 
only  slightly  turbid  and  matted  together ;  but  usually  there 
is  a  fibrino-purulent  exudate  covering  the  base  and  lat- 
eral surfaces  of  the  brain.  Tubercles  appear  as  small  whitish 
nodules  on  the  membrane,  especially  about  the  Sylvian  fis- 
sure. In  some  cases  they  can  only  be  found  upon  the  arte- 
ries at  the  base  (the  middle  cerebrals  and  those  of  the  per- 
forated spaces).  The  cortex  is  usually  also  oedematous  and 
infiltrated  with  leukocytes.  Areas  of  softening  may  occur  in 
it.  The  ventricles  are  dilated  and  filled  with  turbid  fluid. 
The  spinal  meninges  are  sometimes  also  involved.  A  few 
cases  of  tubercular  pachymeningitis  have  been  reported. 

The  diagnosis  depends  upon  the  discovery  of  a  tubercular 
focus  elsewhere,  or  in  the  possession  of  a  tubercular  heredity 
by  the  child,  and  the  long  duration  of  prodromes.  The  fluid 
withdrawn  by  lumbar  puncture  may  contain  either  tubercle 
bacilli  or  be  sterile  ;  if  the  latter  occurs  when  symptoms  of 
meningitis  are  present,  it  is  most  likely  tubercular.  Men- 
ingitis due  to  infection  from  middle-ear  disease  or  cerebro- 
spinal meningitis  might  be  mistaken  for  it.  The  distinctive 
features  between  it  and  brain-tumor  are  given  on  p.  280. 

The  prognosis  is  most  grave;  recoveries,  if  they  ever  take 
place,  are  most  rare. 

Tubercular  meningitis — treatment :  This  is  similar  to  that  of 
acute  simple  meningitis.  Bleeding,  of  course,  would  not  be 
indicated  in  this  form.  Small  doses  of  potassium  iodide  fre- 
quently repeated  have  been  extolled,  as  have  also  the  inunc- 
tion of  a  10  per  cent,  ointment  of  iodoform  into  the  shaven 
scalp.  As  the  subjects  are  ill-nourished,  supporting  treat- 
ment is  indicated. 

SEROUS  MENINGITIS. 

Etiology — symptoms :  Under  this  title  Quincke  has  de- 
scribed a  form  of  meningeal  inflammation  characterized  by 
serous   effusion    into   the    membranes   and   ventricles.      The 


ALCOHOLIC  MENINGITIS.  185 

nature  of  the  affection  has  not  been  made  out.  In  some 
cases  at  least  it  is  an  inflammation  of  the  ependyma,  'J'he 
onset  may  be  sudden  or  gradual,  and  the  course  acute  or 
chronic.  It  foHows  infectious  diseases,  chronic  diarrhoea, 
traumatism,  and  influences  which  depress  or  deteriorate  the 
general  health.  It  occurs  usually  in  childhood  and  youtii. 
Fever  is  usually  absent;  if  present,  it  is  slight  and  irregular. 
Headache  may  be  absent,  and  rigidity  of  the  cervical  muscles 
is  uncommon.  The  symptoms  usually  present  are  mild  deli- 
rium, insomnia,  vomiting,  slow  and  irregular  pulse,  epilepti- 
form convulsions,  local  palsies,  and  optic  neuritis,  which 
occurs  very  frequently.  It  must  be  remembered,  however, 
that  the  symptoms  may  be  as  severe  as  those  of  other  forms 
of  meningitis. 

Serous  meningitis — diagnosis  :  The  acute  form  must  be  dis- 
tinguished from  purulent  and  tubercular  meningitis.  The 
presence  of  fever,  of  a  focus  of  suppuration  elsewhere,  and 
the  absence  of  optic  neuritis  (if  vertical),  would  distinguish 
the  former.  The  diagnostic  features  of  the  latter  are  men- 
tioned on  p.   184. 

The  chronic  form  may  so  resemble  the  symptoms  of  brain- 
tumor  that  it  may  often  be  impossible  to  distinguish  the  two. 
The  symptoms  following  any  of  the  causes  mentioned  would 
point  to  meningitis,  while  the  presence  of  definite  local  symp- 
toms, paralysis,  or  spasms  would  point  to  tumor. 

The  prognosis  is  grave,  but  recovery  may  occur ;  even  then 
hydrocephalus  often  remains. 

The  treatment  of  the  acute  form  consists  of  similar  meas- 
ures to  those  employed  in  other  forms.  The  chronic  form 
may  be  treated  by  counterirritation  to  the  back  of  the  neck, 
mercurial  or  iodoform  inunctions,  and  in  grave  cases  by  the 
abstraction  of  5  to  8  c.c.  of  fluid  by  lumbar  puncture. 

ALCOHOLIC  MENINGITIS. 

Etiology :  This  term  has  been  applied  to  a  group  of  symp- 
toms following  prolonged  indulgence  in  alcohol.  According 
to  Dana,  it  is  not  a  true  inflammation,  but  an  acute  toxaemia 
of  the  brain  with  serous  effusion  (serous  meningitis).  Per- 
sistent use  of  opium,  cocaine,  and  chloral  may  lead  to  the 


186  INFLAMMATION  OF  THE  MENINGES. 

same  thing.  The  exciting  cause  is  usually  a  spree  lasting  two 
or  three  weeks,  which  may  or  may  not  be  followed  by  deli- 
rium tremens. 

Symptoms  :  The  patient  after  two  or  three  days  of  delirium 
sinks  into  a  semi-coma,  which  is  accompanied  by  a  muttering 
delirium,  flitting  delusions,  and  hallucinations  of  sight  and 
hearing.  The  pulse  is  rapid  ;  the  temperature  may  be  slightly 
elevated  or  normal.  The  skin  is  hypersesthetic  and  the  pupils 
are  contracted.  Slight  muscular  rigidity  is  present  and  the 
head  may  be  slightly  retracted.  There  may  be  incontinence 
of  urine  and  fseces,  and  tlie  tongue  is  coated  and  dry.  The 
disease  may  not  advance  beyond  this  stage,  and  in  three  or 
four  weeks  recovery  is  assured.  Or  the  diseases  advances, 
the  coma  deepens,  the  temperature  rises,  the  pulse  becomes 
feeble,  the  extremities  cold,  and  death  ensues. 

Alcoholic  meningits — morbid  anatomy  :  The  brain  is  pale, 
the  pia  arachnoid  saturated  with  fluid,  and  the  ventricles 
dilated.  Sections  of  the  brain  may  show  punctate  hemor- 
rhages, sometimes  areas  of  softening.  The  beginning  of  a 
purulent  meningitis  may  be  occasionally  seen.  The  brain- 
tissue  is  also  oedematous  and  the  nerve-cells  show  various 
stages  of  degeneration. 

Alcoholic  meningitis — diagnosis  and  prognosis  :  The  previous 
history  of  the  patient,  absence  of  fever,  convulsions,  paraly- 
sis, and  the  occurrence  of  low  delirium  and  hallucinations, 
distinguish  the  affection  from  suppurative  meningitis.  The 
absence  of  pyrexia,  convulsions,  and  paralysis,  and  the  pres- 
ence of  hyperagsthesia,  rigidity,  and  contracted  pupils  differ- 
entiate it  from  encephalitis.  The  prognosis  is  grave.  Dana 
says  that  if  the  patient  has  not  a  stiff  neck  he  will  get  well ; 
but  if  this  develops,  he  will  die. 

The  treatment  consists  in  a  thorough  cleansing  by  purga- 
tives of  the  gastro-intestinal  tract.  The  patient  should  be 
fed ,  liberally  on  beef-tea,  milk  and  eggs,  or  hot  milk  given 
every  two  hours.  Stimulants  must  be  avoided  if  possible. 
Strychnine  may  be  substituted  if  necessary.  An  ice-bag 
should  be  applied  to  the  head  and  leeches  or  large  blisters  to 
the  back  of  the  neck.  When  the  patient  becomes  comatose 
the  removal  of  fluid  by  lumbar  puncture  may  be  tried.  (For 
syphilitic  meningitis,  see  Syphilis  of  the  Nervous  System.) 


CHRONIC  HYDROCEPHALUS.  187 

CHRONIC  CEREBRAL  LEPTOMENINGITIS. 

Etiology:  This  is  usually  secondary  t(»  acute  attacks  or 
brain-tumor ;  but  may  be  primary  in  syphilitics,  alcoholics, 
after  infectious  diseases,  in  the  insane,  and  following  trauma- 
tism or  sunstroke. 

The  symptoms  in  general  are  those  of  acute  meningitis,  but 
are  much  less  severe.  There  may  be  local  symptoms,  spasms, 
paralysis,  etc.,  according  to  the  situation  of  the  inflamed  area. 

Morbid  anatomy:  The  membranes  are  thickened  or  often 
adherent  to  the  cortex  and  dura.  Exudations  of  lymph  are 
present.  The  bloodvessels  are  thickened,  and  if  the  process 
is  of  long  duration  atrophy  of  the  cortex  is  present.  The 
appearances  in  syphilitic  cases  are  described  elsewhere. 

Chronic  cerebral  leptomeningitis — diagnosis  :  The  disease  may 
be  confounded  with  brain-tumor,  chronic  nephritis,  hysteria, 
and  neurasthenia.  In  tumor  the  symptoms  are  more  intense 
and  localized.  Optic  neuritis,  if  present,  is  of  a  higher 
grade ;  it  should  be  remembered  that  the  two  may  be  asso- 
ciated. An  examination  of  the  urine  and  the  presence  of 
albuminuric  retinitis  will  distinguish  nephritis.  The  presence 
of  cranial  nerve  paralyses,  optic  neuritis,  and  the  previous 
history  will  enable  one  to  distinguish  between  organic  disease 
and  hysteria  and  neurasthenia. 

The  prognosis  is  unfavorable.  It  is  best  in  those  cases 
due  to  sunstroke,  traumatism,  or  syphilis. 

The  treatment  consists  in  the  use  of  mercury  and  potassium 
iodide  and  persistent  active  counterirritation  at  the  back  of 
the  neck.  Ergot  and  bromides  are  sometimes  of  service. 
Pain,  insomnia,  and  impairment  of  the  general  healthy  must 
be  treated  by  the  usual  measures  employed  for  such  conditions. 

CHRONIC  HYDROCEPHALUS. 

This,  while  not  an  inflammation,  may  be  conveniently  dis- 
cussed here. 

Definition:  It  is  a  disease  of  infancy,  characterized  by 
gradual  enlargement  of  the  head  and  symptoms  of  brain- 
irritation  and  of  mental  deficiency.  It  begins  within  the 
first  six  months  of  life,  and  usually  in  rachitic  or  poorly 
nourished    children,  whose  parents    have    been    subjects  of 


188  INFLAMMATION  OF  THE  MENINGES. 

syphilis,  alcoholism,  or  lead-poisoning.  It  may  be  present 
at  birth. 

The  symptoms  are  a  gradual  increase  in  the  size  of  the 
head  (which  becomes  pear-shaped),  but  not  of  the  face ; 
bulging  of  the  fontanelles ;  restlessness ;  irritability ;  poor 
general  nutrition ;  strabismus,  and  sometimes  optic  atrophy. 
The  child  does  not  or  imperfectly  learns  to  talk  and  walk. 
Finally  convulsions  and  coma  occur,  and  death  usually  takes 
place  in  two  to  three  years. 

Etiology :  It  may  develop  late  in  life,  due  to  brain-tumor 
or  other  process  obstructing  the  veins  of  Galen  and  aqueduct 
of  Sylvius,  which  causes  an  accumulation  of  fluid  in  the  ven- 
tricles. In  children  it  is  probably  due  to  an  obliteration  of 
the  aqueduct  or  foramen  of  Magendie  from  inflammatory  or 
other  cause. 

The  diagnosis  must  be  made  from  rickets.  In  this  the 
head  is  square,  the  fontanelles  do  not  bulge,  and  other  signs 
of  the  disease  are  present ;  and  from  brain-tumor,  for  the 
differential  points  from  which  see  p.  280. 

The  prognosis  is  not  good  ;  but  in  mild  cases  the  process 
may  cease  and  adult  life  be  reached. 

Treatment  is  of  not  much  avail.  Mercury,  potassium 
iodide,  tonics,  and  nutrients  may  be  given. 

ACUTE  AND  CHRONIC  SPINAL  LEPTOMENINGITIS. 

Etiology :  Primm^y  spinal  leptomeningitis  is  a  rare  affec- 
tion ;  it  may  be  due  to  streptococcus  infection  derived  from 
suppurative  lung  and  pleural  disease  ;  puerperal  septicaemia ; 
and  to  the  toxins  of  any  of  the  various  acute  infectious  dis- 
eases. Spinal  meningitis  most  commonly  occurs  in  connec- 
tion with  or  extension  from  inflammation  of  the  cerebral  pia 
mater  or  spinal  dura  mater.  The  most  frequent  cause  of  the 
former  is  epidemic  cerebro-spinal  meningitis ;  but  it  some- 
times may  be  due  to  extension  of  a  tubercular  or  purulent 
meningitis.  Inflammation  of  the  dura  due  to  any  of  the 
causes  mentioned  on  p.  174   may  extend  to  the  pia. 

Morbid  anatomy :  Acute  primary  cases  show  usually  a  sup- 
purative exudate  distributed  along  the  cord,  but  more  marked 
posteriorly,  and  increase  pf  the  spinal  fluid.  If  the  disease 
lasts  any  time,  the  purulent  matter  partly  disappears  and  con- 


ACUTE  AND  CHRONIC  SPINAL  LEPTOMENINGITIS.   189 

nective  tissue  takes  its  place.  The  dura,  pia,  and  arachnoid 
become  matted  together  and  adlierent  to  the  cord.  Cases  due 
to  tubercular  infection  present  similar  appearances  to  the  cere- 
bral form.  Cases  secondary  to  dural  inflammation  present 
the  appearance  above  described  plus  those  of  pachymeningitis 
described  on  p.  177. 

Symptoms :  In  acute  cases  the  onset  may  be  with  a  chill 
and  fever.  There  is  pain  in  the  back  radiating  along  the 
nerves ;  muscular  rigidity  and  spasms,  and  hypersesthesia  of 
the  skin.  There  are  constipation  and  sometimes  retention  of 
urine.  As  the  disease  progresses  paralysis,  anaesthesia,  reten- 
tion or  incontinence  of  urine  ensue,  and  finally  death  in  from 
a  few  days  to  several  weeks. 

In  the  chi'onic  form  the  symptoms  are  practically  those  of 
pachymeningitis.  AVhen  the  cord  is  involved  the  disease  is 
often  termed  meningo-myelitis. 

Acute  and  chronic  spinal  leptomeningitis — diagnosis :  Myeli- 
tis, tetanus,  strychnine-poisoning,  rheumatism  of  the  dorsal 
muscles  might  be  mistaken  for  the  acute  form.  In  myelitis 
there  is  little  or  no  pain,  and  the  paralysis  appears  almost  im- 
mediately and  is  more  pronounced.  Tetanus  is  associated  with 
spasms  of  the  muscles  that  move  the  jaw,  the  convulsions 
are  more  severe,  and  high  fever  is  present.  In  strychnine- 
poisoning  sensory  symptoms  and  fever  would  not  be  present. 
Rheumatism  of  the  dorsal  muscles  is  not  associated  with 
muscular  spasms  or  radiating  pains. 

The  chronic  form  might  be  mistaken  for  the  tender  spine 
of  neurasthenia  (spinal  irritation),  locomotor  ataxia,  and 
myelitis.  In  spinal  irritation  there  are  not  radiating  pains, 
muscular  rigidity  or  spasms,  paralysis,  and  general  hyper- 
sesthesia. In  locomotor  ataxia  muscular  twitchings,  paralysis, 
spinal  tenderness,  and  general  hypersesthesia  do  not  occur. 

The  prognosis  in  both  forms  is  not  good ;  the  acute  may, 
however,  pass  into  the  chronic  stage,  the  prognosis  of  which 
is  the  same  as  that  of  pachymeningitis. 

The  treatment  of  the  acute  form  consists  of  rest  and  quiet, 
ice-bags  or  hot  applications  along  the  spine ;  in  the  robust 
local  abstraction  of  blood  by  leeches  or  cups ;  mercurial 
purges,  and  ergot  and  bromides  internally.  The  treatment 
of  the  chronic  form  is  similar  to  that  of  pachymeningitis. 


CHAPTER    X. 

SYSTEM    DISEASES. 

Certain  diseases  of  the  nervous  system  are  confined 
either  entirely  or  in  greater  part  to  one  of  the  tracts  or 
systems  of  neurons  described  on  page  22.  Thus  locomotor 
ataxia  is  a  disease  confined  usually  to  the  sensory  tract;  in 
some  cases,  however,  motor  neurons  may  also  suffer.  Progres- 
sive muscular  atrophy  is  a  disease  of  the  motor  tract.  Such 
diseases  are  called  system  diseases. 

DISEASES  OF  THE  SENSORY  OR  AFFERENT  TRACT. 
Locomotor  Ataxia. 

Definition :  This  disease,  also  known  as  posterior  spinal 
sclerosis  and  tabes  dorsalis,  is  progressive,  and  is  character- 
ized usually  by  incoordination  of  movements,  various  sensory 
and  trophic  disturbances,  and  impairment  of  the  special 
senses,  especially  the  eye.  It  is  due  to  disease  of  the  pos- 
terior nerve-roots,  posterior  columns  of  the  cord,  and  at  times 
of  the  spinal  ganglia  or  of  the  peripheral  nerves,  and  nerves 
of  special  sense. 

Owing  to  its  being  in  general  use,  the  name  "  locomotor 
ataxia "  will  be  used ;  but,  as  will  be  seen  below  in  the  de- 
scription of  the  symptoms,  the  disease  may  exist  without  no- 
ticeable ataxia  being  present.  Hence  "  tabes  dorsalis  "  would 
be  a  better  name  for  the  disease. 

Etiology :  Locomotor  ataxia  is  one  of  the  most  common 
of  organic  diseases  of  the  nervous  system.  Males  are  more 
frequently  attacked  than  females,  A  majority  of  the  cases 
occur  between  the  thirtieth  and  fortieth  years,  but  may  occur 
as  early  as  ten  or  as  late  as  sixty  years  of  age.  The  most 
important  cause  is- syphilis,  about  75  percent,  of  all  cases 
having  a  history  of  this  disease,  the  primary  stage  occurring 

190 


LOCOMOTOR  ATAXIA.  191 

ten  to  twenty  years  previously.  It  is  a  "  para-syphilitic " 
disease,  or  one  in  which  the  patient  has  had  syphilis,  but  in 
which  the  characteristic  lesions  of  syphilis  are  not  present 
and  are  not  specially  inHuenced  by  specific  treatment.  In 
other  words,  the  probable  way  in  which  syphilis  j)roduces  the 
disease  is  by  its  leaving  a  toxic  principle  of  some  sort  in  the 
blood  which  acts  upon  the  sensory  neurons,  especially  in  the 
posterior  roots,  and  causes  them  to  degenerate  ;  this  degenera- 
tion not  being  different  anatomically  from  that  produced  by 
other  causes. 

Excessive  fatigue,  sexual  excesses,  exposure  to  cold  and 
wet  are  apparently  causes  in  some  cases. 

Morbid  anatomy  and  pathology  :  Microscopically,  the  follow- 
ing changes  may  be  noticed  :  the  pia  mater  between  the  pos- 
terior roots  is  thickened  and  opaque ;  the  posterior  roots  may 
be  either  enlarged  or  in  advanced  cases  thinner  and  more 
translucent ;  the  spinal  cord  is  reduced  in  size,  and  the  pos- 
terior columns  appear  shrunken  and  have  a  grayish  appear- 
ance. 

Microscopically ,  the  first  changes  are  found  in  the  posterior 
roots,  usually  the  lumbar,  and  the  tract  of  Lissauer.  Sclerosis 
will  a  little  later  be  found  in  Burdach's  columns,  being  first 
noticed  along  the  median  side  of  the  posterior  horns  and 
spreading  out  toward  the  postero-median  septum  as  the  disease 
advances  upward,  and  finally  involving  the  columns  of  Goll 
in  the  upper  thoracic  and  cervical  regions. 

The  fine  fibres  coming  from  the  posterior  roots,  which  run 
to  the  column  of  Clarke,  are  also  sclerosed;  but  the  cells 
themselves  are  usually  not  destroyed,  and  consequently  the 
direct  cerebellar  tract  is  but  rarely  degenerated. 

In  advanced  cases  sclerosis  of  Gowers's  tract  may  be  ob- 
served. In  rare  instances  the  process  may  begin  in  the 
sacral,  upper  thoracic,  and  cervical  roots. 

Changes  in  the  spinal  ganglia  are  present  in  some  cases, 
but  usually  they  are  not  found,  although  by  some  (Marie, 
Marineseo,  and  others)  the  primary  seat  of  the  trouble  is 
thought  to  be  there  situated.  Others  (Obersteiuer  and  Red- 
lich)  have  advanced  the  theory  that  the  primary  cause  is  a 
meningitis  which  makes  pressure  upon  the  root-fibres,  which 
ill  this  situation  are  poor  in  myelin.      While  it  is  not  settled 


192  SYSTEM  DISEASES. 

that  this  is  the  manner  in  which  the  posterior  roots  are  at- 
tacked, it  is  probable  that  they  are  the  primary  seat  of  the 
disease. 

In  addition  to  changes  in  the  cord,  others  are  more  or  less 
frequently  found.  The  descending  roots  of  the  fifth  and 
glosso-pharyngeal  nerves  may  be  degenerated.  The  optic 
nerve  is  frequently  so  affected.  Other  cranial  nerves  and 
their  nuclei,  especially  the  pneumogastric  and  motor  nerves 
of  the  eye,  may  also  be  affected,  respectively  causing  when 
present  the  visceral  crises  and  palsies  of  the  ocular  muscles. 
The  spinal  nerves  also  may  be  found  degenerated,  which  ac- 
counts for  the  muscular  atrojDhy  and  weakness  sometimes 
present. 

Locomotor  ataxia — symptoms  :  These  are  best  considered  by 
dividing  the  progress  of  the  disease  into  three  stages — viz., 
the  incipient,  or  preataxic  ;  ataxic  ;  and  paralytic. 

The  symptoms  of  the  incipient  stage  are  of  especial  im- 
portance, as  a  recognition  of  the  presence  of  the  disease  in 
this  stage  may  be  of  the  greatest  value  to  the  future  welfare 
of  the  patient. 

Pain  is  a  frequent  early  sym])tom  ;  it  is  usually  character- 
istic, being  sharp,  shooting,  and  lancinating,  and  usually  in  the 
legs.  Dull  pains  resembling  those  of  rheumatism  may  also 
occur.  In  some  cases  a  girdle-pain  or  sense  of  constriction 
about  the  body  may  be  com])lained  of.  Various  forms  of 
parsesthesia,  as  numbness  and  tingling  of  the  feet,  a  sensa- 
tion as  if  walking  on  feathers  or  something  soft,  are  often 
present. 

Visceral  symptoms,  or  the  so-called  "  crises,"  are  rare — they 
may  be  present  in  this  stage  or  may  not  occur  until  later.  When 
present  they  consist  of  violent  paroxysms  of  pain  referred  to 
various  viscera,  most  commonly  the  stomach  or  larynx  ;  but 
nephritic,  rectal,  urethral,  and  clitoral  crises  have  been  de- 
scribed. In  the  gastric  crisis  there  are  violent  pains  in  the 
stomach,  incessant  vomiting,  and  the  secretion  of  hyperacid 
gastric^  juice.  The  attack  ujay  last  for  days.  It  may  consist 
of  the  pain  alone.  In  the  laryngeal  crisis  there  are  dyspnoea 
and  noisy  inspiration. 

Often  among  tlie  first  sym])toms  complained  of  are  difficulty 
in  emptying  the  bladder  or  in   starting  the  stream  of  urine  ; 


LOCOMOTOR  ATAXIA.  193 

and  decrease  in  sexual  power  and  desire.  Ocular  symptoms, 
when  they  occur,  are  of  great  significance.  They  consist 
of  (a)  optic  atropliy,  the  most  common,  evidenced  by  decreasing 
loss  of  vision,  sometimes  ending  in  blindness;  (h)  paralysis 
of  any  or  all  of  the  external  ocular  muscles,  evidenced  by 
ptosis,  single  or  double,  or  squint  and  double  vision  ;  these 
paralyses  are  often  transient,  and  a  temporary  diplopia  may 
be  the  only  symptom  complained  of;  (c)  a  reflex  iridoplegia 
or  Argyll-Robertson  pupil  (see  p.  116).  The  pupils  are  in 
most  cases  contracted,  often  unequally  so.  Alterations  of  the 
senses  of  smell  and  taste,  either  absence  or  perversion,  may 
occur  either  as  an  early  symptom  or  later. 

One  of  the  earliest  and  most  significant  symptoms  is  the 
loss  of  the  knee-jerk.  This  occurs  by  a  gradual  decrease,  may  be 
lost  in  one  leg  before  the  other,  and  often  precedes  for  several 
years  the  development  of  the  ataxia.  In  those  rare  cases 
where  the  disease  commences  above  the  lumbar  enlargement 
it  is  preserved. 

Trojyhic  disturbances,  as  an  arthropathy  or  perforating  ulcer 
of  the  foot,  are  rarely  early  symptoms.  These  will  be  de- 
scribed later.  The  Romberg  symptom  and  other  evidences 
of  ataxia  (see  p.  47)  may  or  may  not  be  present  in  this  stage ; 
usually  the  application  of  the  finer  tests  for  ataxia  (see  p.  47) 
will  reveal  its  presence  in  some  degree.  Some  cases  never 
advance  beyond  this  stage.  This  is  especially  true  of  those 
in  which  optic  atrophy  is  an  early  symptom  ;  such  cases  are 
known  as  the  amaurotic  form. 

Ataxic  stage:  One  of  the  first  symptoms  of  this  stage  is 
the  inability  to  walk  with  facility  in  the  dark.  Examination 
will  reveal  the  presence  of  the  Romberg  symptom,  and  the 
patient  will  respond  imperfectly,  or  not  at  all,  to  the  various 
tests.  Gradually  the  characteristic  gait  appears  :  the  patient 
walks  with  his  eyes  fixed  upon  the  ground  and  the  legs  wide 
apart.  The  foot  is  raised  high  and  thrown  out  with  a  sort 
of  jerk,  and  is  brought  down  hard,  with  the  heel  usually  first. 
In  the  course  of  time  assistance  in  the  shape  of  one  or  two 
canes  has  to  be  employed.  Incoordination  in  the  move- 
ments of  the  hands  and  arms  may  or  may  not  be  present; 
in  those  cases  in  which  the  cord  is  first  affected  high  up  they 
:ire  involved  first. 

13— X.  D. 


194  SYSTEM  DISEASES. 

In  this  stage  there  is  no  loss  of  muscular  power,  but  there 
may  be  great  muscular  relaxation,  which  permits  greater  mo- 
bility of  the  joints  than  normal. 

The  sensory  symptoms  that  occur  at  this  time  are  varied. 
The  shooting-pains  may  persist  or  may  be  absent.  Bands  of 
aneesthesia  about  the  body,  following  the  sensory  distribution 
of  the  spinal  segments,  may  be  found  (segmental  or  spinal 
type,  see  Spinal  Localization).  In  the  legs  appreciation  of 
painful  stimuli  is  usually  delayed,  and  sometimes  there  is 
inability  correctly  to  localize  sensory  impressions  (allocheiria, 

P-43).  .  ... 

Muscle-sense,  especially  the  inability  to  recognize  position, 
becomes  much  impaired.  Parsesthesise  such  as  have  been 
previously  described  persist. 

The  knee-jerks  remain  as  in  the  preataxic  stage,  while  the 
skin-reflexes  are  often  increased. 

The  Argyll-Robertson  pupil  persists,  and  optic  atrophy  is 
usually  found  ;  but  as  has  already  been  stated,  cases  in  which 
this  symptom  is  marked  frequently  do  not  reach  this  stage. 
Deafness,  which  may  be  associated  with  attacks  of  vertigo, 
due  to  degeneration  of  the  auditory  nerve,  rarely  may  develop. 

Crises  are  more  apt  to  occur  in  this  period  than  in  the  pre- 
ataxic. Constipation  is  common.  Retention  of  urine,  with 
the  development  of  cystitis,  may  appear  and  the  sexual  power 
grows  weaker. 

It  is  in  this  period  of  the  disease  that  trophic  symptoms  are 
most  apt  to  occur :  Herpes  sometimes  appears  in  the  course 
of  the  shooting-pains.  The  nails  become  thickened,  ridged, 
and  brittle,  and  onychia  may  develop.  A  perforating  ulcer, 
usually  located  beneath  the  big  toe,  may  appear.  Lesions  of 
the  joints,  the  so-called  arthropathies,  or  Charcot's  joints, 
when  present  usually  affect  the  knee,  but  other  joints  may 
suflTer.  They  consist  of  painless  swellings,  due  to  effusion 
into  the  joint,  attended  with  destruction  of  the  cartilages 
and  bones,  and  possibly  suppuration,  causing  dislocation  and 
deformity.  The  bones  may  become  brittle  and  liable  to  fract- 
ure from  the  slightest  causes.  Muscular  atrophy,  due  prob- 
ably to  neuritis,  sometimes  occurs. 

In  this  stage  mental  symptoms  sometimes  develop  ;  paretic 
dementia  sometimes  coexists,  either  following  the  appearance 


LOCOMOTOR  ATAXIA.  195 

of  the  tabes  or  vice  versa.  Either  melancholia  or  simple  de- 
mentia may  also  be  developed  in  ataxics. 

After  tlie  symptoms  above  described  have  persisted  for  an 
indefinite  period,  from  three  to  thirty  years,  and  the  patient 
does  not  die  of  some  intercurrent  malady,  the  symptoms  of 
the  paralytic  stage  usually  develop,  in  which  muscular  weak- 
ness makes  its  appearance,  and  the  patient  gradually  loses 
the  power  of  walking  and  becomes  bedridden.  In  this  con- 
dition the  patient  may  live  a  long  time. 

Locomotor  ataxia — diagnosis  :  The  early  recognition  of  the 
trouble  is  of  great  importance.  Loss  of  knee-jerk,  associated 
with  one  or  all  of  the  following  symptoms — viz.,  lightning- 
pains,  optic  atrophy,  ocnlar  palsies,  especially  the  Argyll- 
Robertson  pupil — should  justify  a  provisional  diagnosis, 
which  is  rendered  still  more  positive  if  a  history  of  syphilis 
can  be  obtained.  All  of  the  symptoms  above  described  do 
not  occur  in  every  case  of  ataxia.     Many  of  them  rarely  do. 

When  the  disease  is  fully  developed  it  may  be  confounded 
with  the  following  diseases  : 

Multiple  neuritis,  which  differs  from  tabes  in  the  early  de- 
velopment of  motor  paralysis  and  muscular  atrophy,  hyper- 
sesthesia,  tenderness  of  the  nerve-trunks,  and  constant  pain, 
aggravated  by  moN-ement.  Diphtheritic  neuritifi,  in  ^vhich 
sensory  symptoms  are  usually  absent  or  slight;  but  the  pres- 
ence of  paralysis  of  the  muscles  of  the  throat  and  the  liistory 
should  make  the  diagnosis  clear. 

Ataxic  paraplegia,  which  differs  in  the  increase  of  knee- 
jerks,  spasticity  of  the  muscles,  absence  of  pain  and  eye- 
symptoms. 

Myelitis  or  meningo-myelitis,  involving  the  posterior  col- 
umns, presents  symptoms  resembling  tabes.  The  distinguish- 
ing features  are  similar  to  those  of  ataxic  paraplegia. 

Disease  of  the  sensori-motor  region  of  the  cerebral  cortex, 
especially  in  the  superior  parietal  lobule  and  of  the  sensory 
tracts,  may  cause  ataxia,  which,  however,  is  usually  limited 
to  one  limb,  and  is  accompanied  with  other  symptoms  of 
cerebral  disease.  Also  in  spinal  ataxia  the  movements  be- 
come better  regulated  when  under  the  control  of  the  eyes ;  in 
cortical  ataxia  they  do  not. 

Cerebellar  disease  presents  symptoms   of  cerebral  disease, 


196  SYSTEM  DISEASES. 

nausea,  optic  neuritis,  headache ;  the  gait  differs,  being  reel- 
ing, with  a  tendency  to  fall  in  one  certain  direction,  resem- 
bling that  of  a  drunken  man,  instead  of  the  gait  described  as 
ataxic  (pp.  47  and  48).     There  are  no  sensory  symptoms.   . 

General  paresis  may  be  associated  with  tabes,  either  pre- 
ceding it  or  coming  on  in  its  later  stages.  The  peculiar 
mental  and  physical  symptoms  which  are  symptoms  of 
paresis  (p.  39)  will  enable  one  to  recognize  its  presence. 

Visceral  crises,  especially  when  they  occur  as  early  symp- 
toms, may  be  mistaken  for  neuralgia  of  the  affected  part. 
Paroxysmal  attacks  of  visceral  pain  should  cause  an  examina- 
tion to  be  made  for  other  symptoms  of  tabes. 

Prognosis :  As  has  been  already  stated,  locomotor  ataxia 
usually  lasts  a  long  time.  Rarely  it  may  run  its  course  rap- 
idly, the  paralytic  stage  being  reached  in  a  year  or  less.  Many 
cases  remain  in  the  preataxic  stage  for  years.  Some,  especially 
those  associated  with  optic  atrophy,  never  advance  beyond  it. 

While  complete  recovery  rarely  occurs,  much  can  be  done 
to  ameliorate  the  symptoms  avid  to  lengthen  the  period  before 
the  paralytic  symptoms  occur. 

Locomotor  ataxia — treatment :  It  is  well  in  all  cases  who 
are  in  good  physical  condition  that  a  vigorous  antisyphilitic 
treatment  be  kept  up  for  some  months.  In  debilitated  cases 
this  treatment  should  not  be  employed,  excepting  the  com- 
bination of  a  small  dose  of  bichloride  of  mercury  and  tinct- 
ure of  chloride  of  iron,  until  after  the  patient  is  built  up  by 
the  use  of  cod-liver  oil  and  other  nutrients  and  tonics.  While 
anti-syphilitic  remedies  often  fail  to  do  good,  in  a  certain  number 
of  cases  they  seem  to  be  beneficial.  If  after  a  thorough  trial  no 
benefit  is  obtained,  one  of  the  following  drugs  should  be  used  ; 
they  are  named  in  the  order  of  their  etlicacy  ;  long-continued 
courses  of  nitrate  of  silver  (gr.  J  t.  i.  d.),  arsenic,  chloride  of 
gold  and  sodium,  and  glycero-phosphate  of  lime  or  soda. 
Small  doses  of  strychnine  in  cases  associated  with  weakness 
are  often  beneficial.  Where  there  is  much  difficulty  in  uri- 
nating it  is  of  special  service.  In  addition  to  the  use  of 
drugs,  the  patient  must  be  cautioned  not  to  overexert  him- 
self physically  or  mentally  ;  to  abstain  from  alcohol,  excessive 
use  of  tobacco,  and  sexual  indulgence ;  and  he  should  have 
plenty  of  nutritious,  easily-digested  food,  fresh  air,  and  sun- 


DISEASES  OF  THE  MOTOR  NEURONS.  197 

shine.  In  the  early  stages  or  in  greatly  debilitated  cases,  the 
rest-cure  (p.  76)  is  often  of  great  benefit.  Hydrotherapeutic 
measures  may  be  tried  in  the  early  stages.  A  most  valuable 
plan  is  to  cause  the  patient  to  sit  from  one-half  to  one  hour 
in  water  of  a  temperature  of  85°  to  90°  F.  He  is  then 
rubbed  down  and  sprayed  with  a  little  cooler  water,  but  is 
not  shocked  with  cold  water  or  strong  donches.  After  this  he 
rests  for  an  hour. 

Of  the  various  symjitoms  which  need  relief,  pain  is  one  of 
the  most  important.  The  various  analgesic  coal-tar  prepara- 
tions, either  alone  or  in  combination  with  codeine,  often  answer. 
Rest  in  bed  and  counterirritation  by  blister  or  cautery  over 
the  spine  may  be  tried.  When  these  fail  suspension  of  the 
body  from  the  shoulders  and  head  has  often  proved  valuable 
for  this  purpose.  A  similar  effect  may  be  obtained  without 
apparatus  by  placing  the  patient  in  a  sitting  position  with  the 
legs  held  straight  down  in  the  extended  position,  then  grad- 
ually flexing  the  body  upon  the  legs  and  keeping  it  so  for 
several  minutes.  Suspension  must  not  be  employed  where 
heart  or  arterial  disease  is  present,  or  where  there  is  debility, 
and  should  only  be  employed  for  a  short  interval  (thirty  sec- 
onds) at  first,  which  period  may  be  gradually  increased  to  five 
minutes  or  longer.  To  relieve  the  numbness  and  tingling  of 
the  legs,  electricity,  in  the  form  of  faradism,  applied  by  the 
dry  brush,  is  useful.  In  laryngeal  crises  a  few  Avhiffs  of 
chloroform  or  the  inhalation  of  nitrite  of  amyl  will  usually 
suffice.  In  the  other  forms  of  crises  the  coal-tar  preparations 
already  mentioned  are  indicated.  Cannabis  indica  and  in  the 
gastric  crisis  cocaine  should  be  tried,  while  the  diet  is  nutri- 
tious and  easily  digested.  As  a  last  resort  only  should  mor- 
phine be  used.  Osier  recommends,  in  all  cases  associated 
with  increased  arterial  tension,  the  long-continued  use  of 
nitroglycerin  for  the  relief  of  pains  and  crises. 

FrankeFs  method  of  exercise  and  muscle  re-education  de- 
scribed on  p.  72,  should  be  employed  when  the  ataxia  is 
pronounced. 

DISEASES  OF  THE  MOTOR  NEURONS. 
Disease  of  the  motor  neurons  may  be  limited  to  either  the 
central  or  peripheral  neurons,  or  both  may  be  attacked. 


198  SYSTEM  DISEASES. 

DISEASES  OF  THE  CENTRAL  MOTOR  NEURONS. 
Primary  Lateral  Sclerosis. 

Definition :  A  spastic  paralysis  of  the  muscles  of  the  body, 
those  of  the  legs  being  first  and  most  affected,  attended  with 
increased  reflexes  in  the  affected  parts  and  unattended  by 
muscular  atrophy  or  sensory  disturbances. 

Etiology :  Primary  lateral  sclerosis  occurs  most  commonly 
between  the  ages  of  twenty  and  forty,  but  may  appear  earlier 
or  later.  Moyer  has  recently  reported  a  case  in  a  child  of 
five  years.  The  causes  are  not  well  understood.  Some  cases 
have  seemed  to  follow  syphilitic  infection  (Gowers) ;  others 
have  appeared  to  be  due  to  traumatism  to  the  back,  exposure 
to  cold  and  wet,  infectious  diseases,  and  to  causes  producing 
general  physical  debility. 

Primary  lateral  sclerosis — symptoms  :  The  patient  first  com- 
plains of  soon  tiring  and  a  feeling  of  stiffness  in  the  legs, 
and  there  may  be  dull  pains  in  the  back.  The  symptoms  may 
commence  in  one  leg  before  the  other  is  aifected,  or  one  leg 
may  be  affected  more  than  the  other.  The  loss  of  power  in 
most  cases  increa,ses  very  gradually,  and  at  the  end  of  years 
weakness  may  not  be  extreme.  The  spasticity  of  the  muscles 
increases  more  rapidly ;  the  affected  limbs  when  bent  by  the 
examiner  may  at  first  give  a  sensation  similar  to  that  given 
by  the  bending  of  a  piece  of  lead  pipe ;  but  if  the  move- 
ment is  continued,  they  become  more  supple.  In  the  early 
stages  the  only  thing  noticeable  about  the  gait  is  a  tendency 
to  drag  the  toes  and  a  rapid  wearing  off  of  the  toes  of  the 
shoes.  The  gait  in  a  well-marked  case  is  characteristic ; 
the  legs  are  moved  stiffly  and  seem  glued  to  the  ground, 
being  pushed  forward ;  the  toes  are  raised  over  obstacles 
either  wath  great  difficulty  or  not  at  all.  As  the  patient 
begins  to  walk  a  violent  trembling  or  clonus  of  the  legs 
often  occurs.  Owing  to  spasm  of  the  adductors,  the  knees 
are  kept  close  together;  and  in  aggravated  cases  it  may 
cause  the  patient  to  walk  with  one  leg  crossed  over  the 
other,  the  so-called  cross-legged  progression.  The  knee- 
jerk  is  markedly  increased  and  the  ankle-clonus  well  de- 
veloped. The  superficial  reflexes  are  also  more  active. 
The  muscles  are  not  atrophied  and  feel  firm  ;  electrical  reae- 


PRIMARY  LATERAL  SCLEROSIS.  199 

tions  are  normal.  There  may  be  difficulty  in  holding  the 
urine,  but  usually  there  is  no  trouble  with  the  sphincters  until 
late  in  the  disease.  Sensory  disturbances  are  absent.  As  the 
disease  progresses  the  arms  may  also  become  affected. 

Primary  lateral  sclerosis — morbid  anatomy :  The  lesion  is 
a  degeneration  of  the  pyramidal  tracts ;  that  this  may  occur 
primarily  is  not  definitely  settled.  Many  observers  doubt 
if  a  degeneration  of  the  pyramidal  tracts  can  occur  except- 
ing as  a  secondary  degeneration  due  to  a  lesion  higher  up, 
cutting  off"  the  fibres  from  their  parent-cells  in  the  cortex ; 
or  to  a  lesion  of  the  cells  themselves.  A  few  cases  have, 
however,  been  reported  in  which  no  such  lesion  could  be  found. 

Diagnosis:  The  following  diseases  resemble  primary  lateral 
sclerosis  : 

Transverse  myelitis;  in  this,  however,  there  are  sensory 
symptoms,  as  pain  and  anaesthesia,  and  the  sphincters  are  early 
affected. 

Ataxic  paraplegia  differs  in  the  spasticity  of  the  muscles 
not  being  so  marked,  and  evidences  of  lack  of  coordination 
are  present ;  involvement  of  the  sphincters  is  also  common. 

In  amyotrophic  lateral  sclerosis  there  are  soon  developing 
extensive  muscular  atrophy  and  weakness. 

Secondary  degeneration  following  cerebral  apoplexy  may 
be  mistaken  for  the  cases  in  which  one  side  is  more  affected 
than  the  other.  The  history  of  a  previous  apoplectic  attack 
will  settle  the  question. 

Hysterical  paraplegia  may  be  often  most  difficult  to  distin- 
guish. In  lateral  sclerosis  the  spasm  is  most  pronounced 
when  the  limbs  are  extended  ;  as  they  are  flexed  it  diminishes, 
a  condition  which  does  not  occur  in  hysteria.  Also  the  deej) 
reflexes,  while  they  may  be  increased,  are  not  so  much  so  in 
hysteria,  a  true  ankle-clonus  being  exceedingly  rare  in  this  dis- 
ease. Other  evidences  of  hysteria  will  also  often  be  found  if 
searched  for. 

The  progress  of  the  disease  is  steadily  but  slowly  onward, 
until  the  power  of  movement  is  entirely  lost. 

Primary  lateral  sclerosis — treatment :  This  is  not  very  satis- 
factory. Nitrate  of  silver,  arsenic,  chloride  of  gold  and  sodium, 
iodide  of  potassium,  and  bicliloride  of  mercury  may  all  be 
tried.     Rest  may  prove  beneficial,  and  prolonged  warm  baths 


200 


SYSTEM  DISEASES, 


Fig.  36. 


relieve  the  muscular  rigidity.     Massage  may  also  prove  of 
service.     Strychnine  must  not  be  given. 

Spastic  Paralysis  of  Infants  or  Cerebral  Palsies  in 
Children. 

This  may  involve  all  four  extremities  (diplegia);  or  be 
paraplegic  or  hemiplegic  in  its  distribution.  For  convenience, 
all  forms  will  be  here  considered. 

Spastic  Hemiplegia. 

Etiology :  This  f<jrm  usually  sets  in  during  the  first  or  sec- 
ond year ;  cases  occurring  after  five  years 
are  rare.  Neurotic  taints,  alcoholism,  or 
syphilis  in  the  parents  in  rare  instances 
appear  to  act  as  predisposing  causes.  A 
small  number  of  cases,  those  occurring 
soon  after  birth,  are  due  to  difficult  labor 
and  injuries  from  the  forceps.  The  dis- 
ease often  comes  on  after  the  infectious 
fevers.  Traumatism  to  the  head  is  a  rare 
cause. 

Spastic  hemiplegia — symptoms :  In  those 
cases  due  to  injury  at  birth  the  paralysis 
may  be  noticed  immediately  or  soon  after 
birth.  This  cause,  however,  more  com- 
monly produces  diplegia  or  paraplegia, 
and  the  onset  in  most  cases  of  hemiplegia 
is  sudden  and  attended  with  loss  of  con- 
sciousness and  partial  or  general  convul- 
sions lasting  from  an  hour  or  so  to  days. 
Fever  may  be  present.  More  rarely  paral- 
ysis suddenly  occurs  without  loss  of  con- 
sciousness or  convulsions.  When  the 
child  recovers  consciousness,  paralysis 
more  or  less  complete  of  one  side  is 
noticed.     The  face  usually  escapes. 

In  a  few  cases  this  paralysis  grows  less 
as  the  child  advances   in    years,  and  in 
course  of  time  may  almost  disappear.     In  the  majority  of 


Spastic  hemiplegia  with 

epilepsy. 
(Philadelphia  Hospital.) 


SPASTIC  PARAPLEGIA  AND  DIPLEGIA.  201 

cases  a  well-marked  hemiplegia  is  left.  Motion  is  more  or 
less  impaired  and  the  muscles  become  spastic,  the  arm  is 
carried  with  the  forearm  flexed  upon  the  forearm  and  the 
fingers  contracted  (Fig.  36).  The  gait  is  that  characteristic  of 
hemiplegia,  the  toes  being  dragged  and  the  leg  swinging  from 
the  hip  in  the  arc  of  a  circle.  The  reflexes  are  increased.  If 
the  lesion  is  upon  the  left  side  of  tlie  brain,  aphasia  may  be  a 
symptom.  This  is  rarely  permanent.  Occasionally  in  time 
the  muscles  lose  their  rigidity  or  become  more  relaxed  than 
normal  (hypotonia),  and  the  reflexes  may  be  normal  or  dimin- 
ished. There  is  usually  arrest  of  development  or  retardation 
of  growth  in  the  limbs,  which  are  consequently  smaller  than 
those  of  the  other  side.  Vaso-motor  disturbances,  as  cold- 
ness, blueness,  and  congestion  of  the  aifected  parts,  occur. 
Arrest  of  mental  development  occurs  in  a  large  number  of 
these  patients,  and  all  the  various  grades  of  idiocy  and  im- 
becility may  be  found  among  them. 

Epilepsy  is  also  a  frequent  sequel,  41  out  of  135  in  Osier's 
series.  The  seizures  may  be  either  of  the  general,  Jacksonian, 
or  petit  mal  type. 

The  so-called  post-hemiplegic  movements  occur  more  or 
less  frequently.  These  are  tremor,  ataxia  of  the  aifected 
limbs,  sometimes  spoken  of  as  post-hemiplegic  chorea,  and 
athetosis,  which  has  been  described  on  p.  35. 

Spastic  Paraplegia  and  Diplegia. 

Etiology  :  This  aifection  is  also  known  as  Little's  disease  and 
birth-palsy.  The  majority  of  cases  of  hemiplegia  are  not 
congenital,  but  have  their  onset  a  year  or  two  after  birth.  In 
the  form  about  to  be  described  the  opposite  is  the  case,  only 
a  limited  number  occurring  any  length  of  time  after  birth, 
and  the  majority  being  congenital  in  origin.  The  majority 
of  the  children  so  affected  are  born  in  first  and  difficult 
labors,  or  have  been  forceps  deliveries,  A  certain  number 
of  others  have  been  premature  births,  and  the  symptoms  are 
due  to  lack  of  development  of  the  pyramidal  tracts.  Neu- 
rotic taints,  alcoholism,  and  syphilis  in  the  parents  may  in 
these  latter  cases  rarely  have  some  influence.  Injuries  to  the 
abdomen  or  the  occurrence  of  infections  or  exhausting  disease 


202 


SYSTEM  DISEASES. 


during  the  pregnancy  of  the  mother  have  also  appeared  to  be 
causes  in  some  cases. 

Spastic  paraplegia  and  diplegia — symptoms :  In  some  in- 
stances nothing  abnormal  is  noticed  about  the  child  until  it  is 
time  for  him  to  begin  to  walk,  which  he  either  does  not  at- 
tempt at  all  or  else  does  so  with  difficulty.  Often  the  child 
will  be  unable  to  sit  up,  and  the  head  rolls  about  owing  to 
its  not  being  supported  by  the  neck-muscles.  Inquiry  will 
often  elicit  the  fact  that  there  have  been  a  number  of  convul-' 

sions  shortly  after  birth.  In 
well-developed  cases  the  legs 
are  rigid,  and  when  stood  upon 
its  feet  the  weight  is  sup- 
ported upon  the  toes  and  inner 
surface  of  the  feet;  the  knees 
are  held  close  together  owing 
to  adductor  spasm,  or  the  legs 
may  be  crossed  (Fig.  37). 

The  rigidity  of  the  arms 
when  they  are  affected  varies. 
It  may  be  slight,  and  is  evi- 
denced principally  by  awk- 
wardness in  using  the  hands ; 
or  it  may  be  considerable,  and 
the  arms  are  held  in  the  posi- 
tion assumed  by  the  arm  of  a 
hemiplegic.  The  face  is  but 
rarely  affected. 

The  legs  are  usually  more 
affected  than  the  arms.  The 
cases  in  which  the  arms  are  so 
slightly  affected  as  to  be  only 
appreciable  after  careful  ex- 
amination are  known  as  the 
paraplegias.  Spasticity  is 
sometimes  absent.  The  re- 
flexes are  increased  and  the 
muscles  not  wasted  ;  sensory 
disturbances  are  absent.  The  head  is  often  microcephalic. 
Irregular    muscular    movements  are  often   present.      These 


Spastic  paraplegia ;    cross-legged 
gression  (.Teft'erson  Hospital) 


CEREBRAL   PALSIES   OF  CHILDREN.  203 

consist  either  of  constant  movements  of  the  muscles  which 
interfere  with  attempts  at  grasping  an  object  and  similar 
movements  of  the  shoulders,  arms,  and  sometimes  the  head  ; 
or  of  athetoid  movements,  which  in  these  cases  are  most 
pronounced.  These  are  bilateral,  involving  both  hands  and 
feet,  and  are  often  associated  with  irregular  movements  of 
the  facial  muscles,  causing  grimaces  and  distortion  of  the 
features. 

Epileptic  convulsions  occur  in  many  of  the  cases.  Intelli- 
gence may  be  good,  but  the  majority  of  these  patients  are 
idiotic. 

Cerebral  palsies  of  children — morbid  anatomy  :  In  an  analy- 
sis by  Osier  of  ninety  autopsies  in  cases  of  hemiplegia  there 
was  found  either  hemorrhage,  thrombosis,  or  embolism  of  a 
Sylvian  artery  in  sixteen  cases.  In  fifty  cases  there  were 
atrophy  and  sclerosis.  The  wasting  was  either  of  groups  of 
convolutions,  an  entire  lobe,  or  the  whole  hemisphere.  In 
these  cases  the  meninges  were  generally  found  adherent  over 
the  affected  region,  and  the  affected  convolutions  were  smaller 
and  firmer  than  the  normal  ones. 

Porencephalus,  or  a  loss  of  substance,  in  the  form  of  cav- 
ities or  cysts  at  the  surface  of  the  brain,  are  found.  These 
cavities  may  pass  deeply  into  the  hemisphere  or  reach  to  the 
ventricle.  The  primary  changes  in  the  majority  of  the  cases 
of  porencephalus  and  sclerosis  are  not  known.  A  certain 
number  of  cases  of  porencephalus  result  either  from  hemor- 
rhage or  defect  in  development.  Striimpell  believes  that 
when  sclerosis  is  the  lesion  it  is  due  to  an  inflammation  of 
the  gray  matter  (polio-encephalitis).  This  view  has  not  been 
accepted  by  all  neurologists. 

The  diplegias  and  paraplegias  which  make  their  appearance 
shortly  after  birth,  and  also  the  rare  cases  of  hemiplegia 
which  occur  at  this  time,  are  due  to  meningeal  hemorrhage. 
Some  cases  may  be  due  to  foetal  meningo-encephalitis.  The 
anatomical  conditions  found  in  patients  who  have  lived  some 
time  are  atrophy  or  porencephalus. 

The  cases  which  occur  in  children  born  prematurely  are 
often  due  to  non-development  of  the  pyramidal  tracts.  By 
some  it  is  only  these  latter  cases  to  which  the  names  spastic 


204  SYSTEM  DISEASES. 

diplegia  or  paraplegia,  or  Little's  disease,  is  applied.  Some 
cases  may  be  due  to  "■  agenesis  corticalis,"  or  a  defective  de- 
velopment of  the  cellular  elements  of  the  entire  cortex. 

The  following  table    from   Sachs   shows    the   lesions    most 
likely  to  be  present,  according  to  the  time  of  onset : 


MOEBID  LESION. 


~1  Paralysis  of  intra  uter-  j  Large  cerebral  defects  ;  porencephaly.     Defective 
ine  onset.  .,     developnaent  of  pyramidal  tracts.    Agenesis  cor- 

:     ticalis  (highest  nerve-elements  involved). 
Birth-palsies.  i  Meningeal  hemorrhage,  rarely  intracerebral  hem- 

orrhage.   Later  conditions,  ineningo-encephalitis 
I      chronica,  sclerosis,  cysts,  partial  atrophies. 

i  Hemorrhage,  meningeal  and  rarely  intracerebral ; 

thrombosis,  from  syphilitic  endarteritis  and  in 

j     marantic   conditions ;    embolism.     Later  condi- 

_  Acute  (acquired)  palsies.  |      tions,  atrophy,  cysts,  and  sclerosis  (diflfuse  and 

'  lobar). 

Meningitis  chronica. 

Hydrocephalus  (seldom  the  sole  cause),  primary 
encephalitis,  polio-encephalitis  acuta  (Striimpeil). 


Cerebral  palsies  of  children — diagnosis  :  These  aifections  are 
sometimes  mistaken  for  acute  poliomyelitis,  but  a  knowledge 
of  the  differences  in  the  character  of  the  paralysis  due  to 
lesion  of  the  central  and  peripheral  motor  neurons  will  at 
once  distinguish  the  two  (p.  40).  There  may  be  more  diffi- 
culty in  cases  of  mild  type,  in  which  rigidity  and  contractures 
are  but  slight  or  absent  and  the  reflexes  not  increased  ;  but 
the  absence  of  complete  or  partial  DeR,  the  distribution  of 
the  paralysis  and  mode  of  onset,  will  distinguish  the  cerebral 
from  the  spinal  paralysis. 

Patients  in  whom  choreiform  or  athetoid  movements 
are  present,  and  in  whom  the  evidences  of  paralysis  have 
pretty  well  disappeared,  may  be  mistaken  for  chorea.  Atten- 
tion to  the  history,  the  presence  of  increased  reflexes,  evi- 
dence of  slight  paralysis  or  rigidity,  the  peculiarity  and 
rhythm  of  the  movements  in  athetosis,  will  indicate  the  nature 
of  these  movements.  Also  the  rigidity  sometimes  present  in 
rachitic  children  may  be  mistaken  for  the  diplegic  form.  In 
the  former  the  spasm  often  begins  in  the  hands,  and  is  con- 
fined to  the  hands  and  arms.  The  spasms  may  be  painful, 
and  are  intermittent ;  the  laryngeal  muscles  are  often  affected, 


HEREDITARY  SPASTIC  PARALYSIS.  205 

producing  difficult  respiration  (laryngismus  stridulus ;  see 
Tetany). 

The  prognosis,  as  regards  recovery  of  mental  and  physical 
strength,  is  bad.  Most  of  the  cases  which  survive  the  attack 
either  develop  epilepsy,  become  idiotic,  or  are  helpless  cripples. 
A  few  do  not,  but  the  possibility  of  this  latter  result  occur- 
ring cannot  be  told  until  the  child  has  been  under  observa- 
tion for  some  time.  The  non-appearance  or  diminution  in 
frequency  of  convulsions  and  the  absence  of  contractures  are 
favorable  signs.     Aphasia,  if  present,  usually  disappears. 

Cerebral  palsies  of  children — treatment :  In  the  acute  stages 
the  physician  will  usually  be  called  on  account  of  the  convul- 
sions. In  these  cases  he  should  endeavor  to  control  the  con- 
vulsions with  chloroform  and  afterward  administer  bromides  ; 
move  the  bowels  with  calomel,  enjoin  rest  and  quiet,  and 
apply  cold  to  the  head. 

The  treatment  of  the  resulting  paralysis  consists  of  the  use 
of  electricity  to  the  muscles  and  massage  after  the  acute 
symptoms  have  disappeared  (about  two  weeks  after  onset) ; 
and  overcoming  the  tendency  to  contractures  by  passive  move- 
ments. If  these  have  already  developed,  the  orthopaedic  phy- 
sician may  do  much  by  proper  tenotomies  and  the  application 
of  suitable  braces.  The  epilepsy  is  treated  similarly  to  idio- 
pathic epilepsy  (p.  339).  By  special  methods  of  education, 
as  practised  in  institutions  for  feeble-minded  children,  the 
mental  condition  may  often  be  improved. 

Hereditary  Spastic  Paralysis. 

Definition :  This  is  a  rare  condition  affecting  a  number  of 
members  of  a  family  in  the  same  and  different  generations. 
Some  of  the  cases  at  least  appear  to  be  due  to  hereditary 
syphilis.     The  cases  may  assume  a  spinal  or  cerebral  type. 

The  symptoms  :  Spinal  type ;  in  brief,  the  development  in 
infancy  or  childhood  of  spastic  rigidity  and  paralysis  with 
increased  reflexes,  affecting  principally  the  legs  and  without 
cerebral  symptoms — /'.  e.,  mental  deterioration,  epilepsy,  etc. 

A  group  of  cases  differing  somewhat  from  these  has  been 
described  by  Bernhardt  and  Striimpell,  in  which  the  symp- 
toms do  not  begin  until  between  twenty  and  thirty.     At  first 


206  SYSTEM  DISEASES. 

there  is  no  paralysis,  but  rigidity  of  the  legs.  After  a  long 
period  the  arms  may  be  also  affected.  Toward  the  end 
paralysis  of  motion  and  sensation  may  develop. 

Cerebral  type  :  These  cases  are  usually  known  as  amaurotic 
family  idiocy.  The  degeneration  is  not  confined  strictly  to 
motor  neurosis,  but  it  can  be  more  conveniently  described 
here.  The  symptoms,  as  summarized  by  Sachs,  are  :  psychic 
disturbances  that  appear  in  early  life  (one  or  two  years)  and 
progress  to  idiocy  ;  weakness  and  ultimately  paralysis  of  the 
extremities,  which  may  be  either  flaccid  or  spastic  ;  increased, 
decreased,  or  normal  reflexes  ;  partial  followed  by  total  blind- 
ness due  to  changes  in  the  macula  and  atrophy  of  the  optic 
nerve  ;  marasmus  and  death  by  the  end  of  the  second  year. 
It  is  a  family  disease.  Occasionally  nystagmus,  strabismus, 
or  deafness  may  be  present.  Most  of  the  reported  cases  have 
been  in  Jews. 

Hereditary  spastic  paralysis — morbid  anatomy :  The  spinal 
type  appears  to  depend  upon  a  degeneration  of  the  spinal 
portion  of  the  pyramidal  tract  (lateral  columns). 

The  principal  changes  found  in  the  cerebral  type  have  been 
small,  poorly  developed  cerebral  convolutions,  degenerative 
changes  in  the  cells  of  the  cortex  and  medulla,  corpora  quad- 
rigemina,  geniculate  bodies,  third  and  fourth  cranial  nuclei, 
and  in  the  cells  and  fibres  of  the  optic  tract.  Changes  have 
also  been  found  in  the  pyramidal  tracts  and  cells  of  the  gray 
matter  of  the  cord.  It  has  been  thought  by  some  that  these 
changes  are  due  to  a  toxaemia. 

The  diagnosis  must  be  made  from  cerebral  spastic  paralysis 
due  to  hemorrhage.  From  this  the  spinal  form  differs  in  its 
gradual  development,  the  occurrence  of  similar  symptoms 
in  other  members  of  the  family,  absence  of  initial  con- 
vulsions, and  later  cerebral  symptoms.  The  cerebral  type 
will  be  distinguished  by  its  gradual  onset,  absence  of  con- 
vulsions, the  development  of  blindness.  Somewhat  similar 
symptoms  to  the  cerebral  form  may  be  caused  by  hereditary 
syphilis. 

The  prognosis  is  sufficiently  indicated  in  the  account  of  the 
symptoms. 

The  treatment  is  evidently  symptomatic.  Hirsch,  taking 
the  ground  that  the  cerebral  form  is  due  to  a  toxsemia,  recom- 


ACUTE  ANTERIOR  POLIOMYELITIS.  207 

mends  removing  the  child  from  the  breast  and  preventing 
the  mother  from  so  feeding  any  future  children. 

DISEASES  OF  THE  PERIPHERAL  MOTOR  NEURONS. 

Acute  Anterior  Poliomyelitis. 

Definition :  This  disease,  also  known  as  infantile  paralysis, 
is  an  affection  usually  occurring  during  early  childhood,  which 
is  characterized  by  fever,  general  loss  of  power,  followed  by 
recovery  of  most  of  the  affected  muscles,  while  those  in 
which  paralysis  remains  rapidly  atrophy. 

Etiology  :  The  disease  is  most  common  in  the  warm  months. 
The  exact  cause  is  unknown,  but  recent  observations  point 
to  its  being  of  infectious  origin.  Infectious  diseases,  cold, 
traumatism,  overexertion,  and  dentition  have  been  put  down 
as  causes.  Extensive  epidemics  of  the  disease  have  occurred. 
While  most  common  in  children,  adults  may  be  attacked. 

Acute  anterior  poliomyelitis — symptoms  :  In  the  majority  of 
instances  the  patient,  having  previously  been  in  good  health, 
becomes  feverish,  restless,  and  may  complain  of  headache 
and  anorexia.  Rarely  there  may  be  general  cutaneous  hyper- 
sesthesia.  Convulsions  also  may  rarely  occur  at  the  onset. 
At  this  time,  or  soon  after,  more  or  less  general  paralysis  or 
paresis  will  be  noticed.  Most  of  the  muscles,  however,  soon 
recover  in  a  period  varying  from  a  few  days  to  several 
months,  leaving  a  permanent  paralysis  of  one  or  two  limbs, 
or  perhaps  only  a  single  group  of  muscles.  The  constitu- 
tional symptoms  soon  disappear;  indeed,  in  some  cases,  they 
are  so  slight  as  to  escape  notice.  Atrophy  and  flaccidity  of 
the  muscles  that  are  to  be  permanently  disabled  soon  appear, 
and  in  about  a  week's  time  examination  will  show  the  pres- 
ence of  the  De  R,  which  as  a  rule  becomes  typically  devel- 
oped. 

Permanent  paralysis  most  commonly  affects  the  leg  muscles, 
and  the  extensor  groups  more  often  than  the  flexors.  The 
paralysis  affects  groups  of  muscles  acting  functionally  to- 
gether, and  not  groups  that  have  the  same  nerve-supply,  as  is 
the  case  in  neuritis.  Thus  the  deltoid,  biceps,  brachialis  anti- 
cus,  and  supinator  longus,  muscles  which  flex  the  forearm, 
are  often  paralyzed  together. 


208  SYSTEM  DISEASES. 

The  deep  reflexes  are  abolished  in  tlie  affected  limbs.  Sen- 
sory changes  are  absent.  In  severe  cases  retardation  of  the 
growth  of  the  affected  limb  occurs,  so  that  it  is  smaller  than 
its  fellow.  Vaso-motor  changes  are  present,  causing  the 
affected  parts  to  be  cyanosed  and  feel  cold  to  the  touch. 
Owing  to  the  want  of  support  by  the  paralyzed  muscles 
about  them,  the  joints  are  relaxed  and  dislocations  may  occur. 
Also  owing  to  the  over-contraction  of  unantagonized  muscles, 
deformities,  such  as  various  forms  of  talipes,  may  occur.  If 
the  back  muscles  are  involved,  spinal  curvature  may  result. 
While  in  most  cases  the  onset  is  abrupt,  there  are  instances 
in  which  it  is  gradual,  taking  several  days  for  the  disease  to 
develop.  Infrequently  the  l)ulbar  nuclei  of  the  cranial  mo- 
tor nerves  are  also  affected,  with  consequent  paralysis  of  the 
muscles  supplied  by  them  (Acute  Bulbar  Palsy,  p.  210). 

Acute  anterior  poliomyelitis — morbid  anatomy :  Until  re- 
cently the  symptoms  were  thought  to  depend  upon  an  inflam- 
mation of  the  cells  in  the  anterior  horns  of  the  cord,  pro- 
duced by  the  action  of  some  unknown  toxic  agent.  Of  late, 
however,  observations  have  been  made  which  would  tend  to 
show  that  the  primary  action  of  the  poison  was  upon  the 
bloodvessels,  and  that  the  process  is  interstitial  instead  of 
parenchymatous.  Such  being  the  case,  the  acute  poliomye- 
litis is  not  a  true  system  disease,  but  until  further  observa- 
tions have  been  made  may  be  most  conveniently  so  classified. 

Changes  are  most  frequently  found  in  the  lumbar  segments. 
In  the  early  stages  the  cord  will  be  found  redder  and  softer 
than  normal.  Minute  hemorrhages  may  be  present  in  the 
anterior  horns  and  the  bloodvessels  are  distended.  In  old 
cases  the  cord  is  smaller  and  denser.  Upon  section  one  or 
both  the  anterior  cornua  are  found  reduced  in  size,  and  the 
anterior  roots  from  the  diseased  region  are  shrunken  and 
fibrous. 

MicroscopiGolly ,  in  the  early  stages  the  bloodvessels  of  the 
anterior  cornua,  septum,  and  commissure,  will  be  found  dis- 
tended and  surrounded  by  a  wall  of  round  cells,  and  there  will 
also  be  found  an  increase  in  the  growth  of  neuroglia,  due  to 
irritation  by  the  poisonous  agent  which  has  escaped  from  the 
blood.  The  ganglion-cells  are  swollen  and  colorless,  and 
show  the  evidences  of  degeneration,  more   or   less   marked 


ACUTE  ANTERIOR   POLIOMYELITIS.  209 

according  to  the  duration  of  the  disease.  The  cells  in  the 
neighborhood  of  the  vessels  are  more  affected  than  those  re- 
mote, as  well  as  those  groups  of  cells  which  have  the  same 
vascular  supply.  The  fibres  of  the  anterior  roots  show 
Wallerian  degeneration,  and  the  affected  muscles  fatty  degen- 
eration and  atrophy  of  the  fibres.  In  cases  of  long  duration 
the  ganglion-cells  in  the  affected  area  will  be  found  to  have 
more  or  less  completely  disaj)peared.  Atrophy  of  the  central 
convolutions  and  pyramidal  tracts  have  been  also  found  in 
cases  of  long  standing. 

Acute  anterior  poliomyelitis — diagnosis :  Cases  with  severe 
constitutional  disturbances  may  be  mistaken  for  meningitis ; 
the  early  appearance  of  paralysis  and  subsequent  history  of  the 
disease  should  make  the  diagnosis  clear.  Multiple  neuritis 
is  distinguished  by  a  progressive  rather  than  a  retrogressive 
course,  such  as  occurs  in  poliomyelitis ;  by  the  presence  of 
pain,  tenderness  over  the  nerve-trunks,  and  often  anaesthesia  ; 
also  the  paralysis  is  always  symmetrical. 

Acute  transverse  myelitis  is  practically  unknown  in  chil- 
dren, but  may  be  mistaken  in  adults  ;  the  presence  of  anaes- 
thesia, symmetrical  paralysis,  sphincter  paralysis,  and  bed- 
sores are  characteristic  of  transverse  myelitis,  but  not  of 
poliomyelitis.  The  seat  of  the  lesion  in  transverse  myelitis 
is  usually  dorsal,  in  which  event  the  deep  reflexes  would  be 
increased  and  the  muscles  not  wasted. 

The  cerebral  palsies  are  distinguished  by  the  absence  of 
atrophy  and  electrical  changes,  and  the  frequent  occurrence 
of  mental  symptoms.  The  pseudo-paresis  of  rachitic  chil- 
dren is  distinguished  by  the  absence  of  atrophy  and  electrical 
changes,  and  the  characteristic  signs  of  that  disorder. 

Prognosis  :  Death  from  involvement  of  respiratory  centres 
sometimes  occurs  during  the  acute  stage.  After  this  is  past 
the  prognosis  as  regards  life  is  good.  The  electrical  exam- 
ination will  help  us  in  forming  our  ])rognosis  as  regards  the 
idtimate  return  of  ])o\ver  (see  p.  60).  The  possibility  of  the 
development  of  deformities  and  the  [)ossible  retardation  of 
growth  must  l)e  remembered. 

Acute  anterior  poliomyelitis — treatment :  If  seen  in  the  acute 
stage,  perfect  rest,  ])referably  on  the  side  or  with  ice  to  the  spine ; 
laxatives  and  diaphoretics  arc  proper.  After  this  stage  has 
1 1— \.  I).. 


210  SYSTEM  DISEASES. 

passed,  usually  in  three  weeks  at  the  most,  the  use  of  electricity 
and  massage  should  be  begun  (see  p.  72).  The  aifected  limbs 
must  be  kept  warm.  Tonics,  of  which  strychnine  in  full 
doses  occupies  first  place,  should  be  given.  Iron,  phosphorus, 
cod-liver  oil,  and  others  may  be  given  as  circumstances  re- 
quire. If  deformities  or  luxations  occur,  much  can  often  be 
done  by  the  proper  application  of  braces,  and  in  the  case  of 
contractures  by  tenotomies.  Good  results  have  been  reported 
from  the  transplanting  of  the  tendons  of  paralyzed  muscles 
on  to  neighboring  healthy  muscles. 

Chronic  Anterior  Poliomyelitis. 

The  symptoms  of  this  disease,  also  known  as  progressive 
muscular  atrophy  of  the  Alan-Duchenne  type,  are  due  to  a 
degeneration  of  ganglion-cells  in  the  anterior  horns.  At 
times,  however,  the  upper  motor  neuron  also  degenerates, 
when  a  group  of  symptoms  is  produced  which  are  designated 
as  amyotrophic  lateral  sclerosis.  These  two  conditions  may 
therefore  be  conveniently  described  together  under  the  head 
of  lesions  of  both  motor  neurons  (see  p.  222). 

Ophthalmoplegia . 

Ophthalmoplegia,  when  due  to  degeneration  of  the  nuclei, 
is  a  system-disease  of  the  peripheral  motor  neuron.  This 
has  been  described  on  p.  119. 

Bulbar  Palsy. 

Bulbar  palsy  comprises  disease  of  all  or  nearly  all  of  the 
nuclei  of  the  motor  cranial  nerves  from  the  third  to  the 
twelfth.  The  terra  as  commonly  used  refers  to  disease  affect- 
ing the  nuclei  of  the  seventh,  ninth,  tenth,  eleventh,  and 
twelfth  nerves.  Several  forms  are  recognized — i.  e.,  acute, 
chronic,  progressive,  and  asthenic  bulbar  paralysis  : 

Acute  Bulbar  Palsy. 

Etiology :  Acute  bulbar  paralysis  may  be  due  either  to 
hemorrhage  or  thrombus  occurring  in  that  region ;  or  to  the 
influence  of  some  toxic  agent,  in  whicli  case  it  is  analog<His 


CHRONIC  PROGRESSIVE  BULBAR  PALSY.  211 

to  acute  anterior  poliomyelitis.  It  is  this  form  that  is  especi- 
ally considered  here.  When  the  nuclei  of  the  motor  nerves 
of  the  eye  are  attacked  the  disease  is  known  as  polio-encepha- 
litis superior-,  as  has  been  described  on  p.  119.  When  the 
nuclei  from  the  seventh  to  the  twelfth  cranial  nerves  are  in- 
volved, it  is  often  spoken  of  as  polio-encephalitis  inferior. 

In  some  instances  the  two  may  be  combined.  Infectious 
diseases  appear  to  be  a  frequent  predisposing  cause. 

Symptoms  :  Polio-encephalitis  ivferior  usually  begins  with 
headache,  vomiting,  and  vertigo.  Difficulty  in  deglutition  and 
articulation  soon  appear,  and  persistent  hiccough  may  occur. 
The  muscles  of  the  lower  part  of  the  face,  tongue,  palate,  and 
pharynx  become  rapidly  paralyzed,  and  as  a  rule  the  patient 
soon  dies  from  cardiac  and  respiratory  failure.  Conscious- 
ness is  retained  to  the  end.  Tiie  disease  may  spread  upward, 
causing  paralysis  of  some  or  all  of  the  ocular  muscles  (polio- 
encephalitis superior) ;  or  downward,  causing  paralysis  of  the 
limbs  (acute  poliomyelitis). 

The  pathology  and  morbid  anatomy  are  practically  the  same 
as  of  acute  anterior  poliomyelitis. 

The  diagnosis :  Hemorrhage  from  or  a  thrombosis  in  the 
vascular  supply  of  the  medulla  and  pons  is  the  only  con- 
ditions that  could  be  mistaken.  In  these  the  onset  would  be 
more  sudden  than  in  inflammation,  and  the  paralysis  Avould 
not  likely  be  limited  to  the  nuclei  alone.  There  would  likely 
1)6  some  immediate  loss  of  power  in  the  limbs  and  sensory 
symptoms,  due  to  involvement  of  the  motor  and  sensory 
tract  as  they  pass  to  and  from  the  cord. 

The  prognosis  is  usually  fatal. 

The  treatment  consists  of  rest,  strychnine,  and  other  meas- 
ures to  support  the  heart  and  respiration. 

Chronic  Progressive  Bulbar  Palsy. 

Etiology :  This  disease  is  also  known  as  glosso-labio-laryn- 
f/eal  paralysis.  It  is  a  disease  which  occurs  at  the  so-called 
degenerative  period  of  life,  between  forty  and  fifty.  The 
cause  is  not  known. 

Symptoms:  The  first  synipt(»ms  to  attnu-t  ntteutiou  are 
difficulties   in   nrticnlalion.      Trouble  with    the    iini>ii:ils,  as   / 


212  SYSTEM  DISEASES. 

and  r,  are  first  noticed  ;  then  trouble  is  experienced  with 
labials — viz.,  b,  p,  and  v.  Swallowing  next  becomes  im- 
paired, and  regurgitation  of  the  food  occurs,  due  to  involve- 
ment of  the  pharyngeal  and  palatal  muscles.  The  voice  be- 
comes nasal  and  vocalization  more  indistinct. 

As  the  disease  advances  the  muscles  of  the  face  become 
more  involved,  the  lines  become  smoothed  out,  and  expression 
is  lost,  due  to  their  atrophy  and  paralysis.  The  tongue  can- 
not be  protruded  and  is  noticeably  atrophied.  The  saliva 
drips  from  the  sides  of  the  mouth  (drooling).  Fibrillary 
tremors  may  be  detected.  Palatal,  pharyngeal,  and  laryngeal 
reflexes  disappear,  but  the  jaw-jerk  is  frequently  present. 
As  the  disease  progresses  the  cardiac  and  res})iratory  centres 
become  involved  and  death  results. 

Rarely  the  ocular  nuclei  become  involved.  More  fre- 
quently the  disease  extends  down  the  cord  producing  symp- 
toms of  amyotrophic  lateral  sclerosis  or  of  chronic  polio- 
myelitis (p.  222).  The  patient  is  emotional,  laughing  or  cry- 
ing without  cause.     There  are  no  sensory  symptoms. 

Chronic  bulbar  palsy — morbid  anatomy :  The  symptoms  are 
due  to  a  symmetrical  degeneration  and  atrophy  of  the  gan- 
glion-cells comprising  the  motor  nuclei  (Fig.  38)  of  the  ninth 
and  tenth  nerves ;  and  the  nuclei  of  the  seventh  and  twelfth 
and  rarely  of  the  motor  nerves  of  the  eye. 

Diagnosis :  The  disease  may  be  confounded  in  the  early 
stages  with  the  similar  stage  of  paretic  dementia,  but  in  the 
former  the  absence  of  the  peculiar  mental  and  pupillary 
symptoms  (Argyll-Robertson)  and  the  appearance  of  diflfi- 
cidty  in  deglutition  will  soon  decide  the  matter.  A  lesion 
confined  to  the  lower  extremities  of  the  central  convolutions, 
or  in  the  lenticular  bodies  of  the  corpora  striatum,  may  pro- 
duce similar  sym.ptoms  to  those  of  bulbar  palsy  ;  such  cases 
are  known  as  pseudobulbar  palsies,  and  are  distinguished  by 
their  frequently  being  asvmraetrical  in  distribution  and  by 
their  sudden  onset  (apoplexy) ;  after  which  they  do  not  pro- 
gress or  may  improve,  unless  another  attack  occurs ;  and  by 
the  absence  of  fibrillary  tremors  and  atrophy  of  the  tongue. 

Asthenic  bulbar  palsy  may  also  be  mistaken.  This  is  de- 
scribed below.  Tumors  of  the  medidla  may  produce  similar 
symptoms,  but  in  such  a  case  both  sides  woidd  probably  not 


CHRONIC  PROGRESSIVE  BULBAR  FALSY. 


213 


be  affected  syiiinietrically,  and  tlic  cortieo-.^piiinl  sensory  and 
motor  tracts  would  also  probably  sufl'er. 


Fig.  38. 


Relative  location  of  the  nuclei  of  the  different  cranial  nerves  (Edinger). 

Implication  of  the  cranial  nerves  by  a  basal  meningitis, 
may  be  confounded  with  it ;  but  in  this  the  paralysis  is  not 
apt  to  be  strictly  symmetrical,  and  nerves  not  involved  in 


214  SYSTEM  DISEASES. 

bulbar  palsy  are  often  involved,  as,  for  wistance,  the  associated 
palsy  of  the  .sixth,  seventh,  and  eiglith.  Headache,  optic 
neuritis,  and  other  symptoms  of  meningitis  would  be  also 
present. 

The  prognosis  is  most  grave.  Few  patients  survive  more 
than  five  years. 

Chronic  bulbar  palsy — treatment :  This  consists  of  measures 
to  improve  the  general  health  and  nutrition.  Physical  and 
mental  rest ;  concentrated,  semi-solid,  and  easily  digested 
foods.  The  use  of  strychnine  and  other  tonics.  The  use 
of  mild  galvanic  currents.  Artificial  feeding  is  usually 
necessary. 

Asthenic  Bulbar  Palsy. 

Definition — etiology :  This  is  a  disorder  in  which  the  symp- 
toms simulate  those  of  chronic  bulbar  palsy,  but  in  which  no 
anatomical  lesion  can  be  found.  Other  parts  of  the  motor 
nervous  system  may  also  be  involved.  The  disease  usually 
occurs  under  thirty.  Traumatism,  syphilis,  physical  and 
mental  exhaustion,  and  emotional  strain  have  been  given  as 
causes.  It  is  most  probably  due  to  the  action  of  some  un- 
known toxic  agent. 

The  symptoms  usually  occur  in  paroxysms,  which  occur  at 
regular  intervals.  Usually  at  first  there  is  a  feeling  of  fatigue 
after  slight  exertion.  Then  articulation  and  deglutition  be- 
come impaired  and  the  limbs  also  may  become  weak.  In 
some  cases  the  symptoms  are  first  manifested  in  transient  and 
shifting  paresis  of  the  ocular  muscles.  Attacks  of  dyspncea 
and  tachycardia  frequently  occur.  The  knee-jerks  are  pres- 
ent, but  easily  exhausted.     Sensory  changes  are  not  present. 

Diagnosis :  From  chronic  bulbar  palsy  the  disorder  is  dis- 
tinguished by  the  absence  of  drooling,  fibrillary  contractions, 
and  atrophy  of  the  affected  muscles  ;  and  the  patient  recovers 
from  the  most  severe  attacks.  The  muscles  supplied  by  the 
third,  motor  division  of  the  fifth,  and  seventh  nerves  are  more 
likely  to  be  affected  than  in  the  organic  affection.  From 
pseudobulbar  palsy  we  distinguish  it  by  the  presence  in  the 
former  of  permanent  paralytic  symptoms,  of  symptoms  point- 
ing to  cerebral  disturbance,  headache,  vertigo,  mental  con- 
fusion, etc. 


^      ACUTE  ASCKNDJNd   PARALYSIS.  215 

The  symptoms  wliicli  distiiiii^iiisli  disenso  of  tlio  nerves  at 
the  base  from  chronic  bulbar  palsy  also  obtain  here.  In 
addition,  mnscular  atrophy  and  changes  in  the  eleetrieal  reac- 
tions would  be  finind. 

Rarely  tumor,  brain  syphilis,  and  hysteria  may  produce 
similar  symptoms.  These  would  be  distinguished  by  the 
presence  of  other  symptoms  of  these  disorders. 

Prognosis :  Severe  cases  may  cause  death.  Usually  the 
patient  has  a  number  of  attacks,  recovering  either  partially 
or  completely  from  all.  The  disease  lasts  from  two  to  four 
years. 

Asthenic  bulbar  palsy — treatment :  Rest,  careful  feeding, 
artificial  if  required.  Strychnine  in  full  doses  and  other 
tonics  and  nutrients,  as  malt  and  cod-liver  oil,  should  be 
given. 

Acute  Ascending  Paralysis. 

Definition — etiology  :  This  disease,  also  known  as  Landnfs 
disease,  is  a  progressive  paralysis,  usually  beginning  in  the 
legs,  involving  the  trunk  and  arras  and  finally  the  muscles 
of  respiration,  without  marked  sensory  symptoms,  and 
changes  in  electrical  reaction.  It  usually  occurs  between  the 
ages  of  twenty  and  thirty.  In  a  number  of  instances  it  has 
followed  the  infectious  diseases,  and  is  probably  due  to  the 
action  of  some  toxic  agent. 

Acute  ascending  paralysis — symptoms :  Weakness  of  the 
legs  is  the  first  symptom,  which  progressively  grows  worse, 
and  often  with  great  rapidity.  The  muscles  of  the  trunk 
next  suffer,  and  in  a  few  days,  or  even  less,  the  arms  are 
affected.  The  muscles  of  the  neck  next  suffer,  and  finally 
those  of  articulation,  deglutition,  and  respiration.  The  re- 
flexes are  lost,  but  the  muscles  do  not  waste  nor  show  elec- 
trical changes.  The  sphincters  usually  are  not  involved. 
Sensory  symptoms  are  as  a  rule  absent,  but  hypersesthesia 
and  various  pai^sesthetic  sensations  have  been  noted  in  some 
cases.  Rarely  the  disease  may  begin  above  and  descend.  En- 
largement of  the  spleen  has  been  noted. 

Morbid  anatomy :  A  number  of  different  anatomical  condi- 
tions have  been  found  in  cases  in  which  a  diagnosis  of  Lan- 
dry's disease  had  been  made.    For  instance,  multiple  neuritis, 


216  SYSTEM  DISEASES. 

poliomyelitis,  and  acute  diffuse  myelitis.  The  symptoms  are 
due  to  the  action  of  a  poison  upon  the  peripheral  motor 
neuron.  Many  of  the  earlier  cases  showed  no  pathological 
changes  Avhatever,  but  with  improved  methods  of  staining 
more  or  less  marked  changes  in  the  ganglion-cells  of  the  an- 
terior horns  have  been  found.  In  some  cases  these  have  been 
associated  with  dilatation  of  the  bloodvessels  and  perivas- 
cular infiltration,  as  in  acute  poliomyelitis.  In  others  there 
has  been  parenchymatous  degeneration  of  these  cells.  Asso- 
ciated with  these  cell-changes  degeneration  of  the  periph- 
eral nerves  is  found.  Mills  and  Spiller  believe  that  in  ad- 
dition to  changes  such  as  above  described,  Landry's  paralysis 
may  be  due  to  a  diffuse  myelitis.  Cases  no  doubt  occur  in 
which  the  toxaemia  is  so  malignant  that  death  occurs  before 
anatomical  changes  develop.  In  one  case  a  micrococcus  re- 
sembling that  of  meningitis  has  been   found. 

The  diagnosis  must  be  made  from  multiple  neuritis,  acute 
poliomyelitis,  and  acute  myelitis.  From  the  first  the  disease 
differs  in  the  absence  of  marked  sensory  symptoms,  muscular 
atrophy,  and  changes  in  the  electrical  reactions.  From  the 
second  it  differs  in  its  progressive  ascending  course  and  in  the 
absence  of  muscular  atrophy  and  changes  in  the  electrical  re- 
actions. From  the  third,  in  the  absence  of  anaesthesia,  bed- 
sores, and  sphincter  paralysis. 

Prognosis  is  usually  fatal.  Death  has  occurred  in  forty- 
eight  hours.  Other  cases  may  persist  for  a  week  or  two. 
Recoveries  have  been  reported. 

The  treatment  consists  of  rest  and  supporting  measures. 
Dana  recommends  warm  baths  or  packs,  counterirritation  to 
the  spine,  and  laxatives.  Large  doses  of  ergot  have  been 
recommended.  Salicylates,  iodide  of  potassium,  and  mercury 
may  be  tried. 

Arthritic  Muscular  Atrophy. 

Definition :  An  atrophy  and  weakness  occurring  in  the 
muscles  about  diseased  joints,  which  bears  no  relation  to  the 
nature,  cause,  or  severity  of  the  joint-affection. 

Etiology  :  Any  joint-inflammation — /.  <?.,  traumatic,  rheu- 
matic, gonorrheal,  or  other  form  of  arthritis — may  cause  it. 

Symptoms  :   Either  during  the  acute  symptoms  in  the  joint 


PROGRESSIVE  MUSCULAR  ATROPHY.  217 

or  after  their  subsidence  atr<»[)hy  is  noticed  in  tlie  muscles 
surrounding  it.  The  extensors  of  and  muscles  to  the  |)rox- 
imal  side  of  the  joint  are  principally  and  may  be  the  oidy 
ones  affected.  Thus,  if  the  shoulder-joint  is  diseased,  the 
deltoid,  triceps,  and  scapular  muscles  are  the  usual  ones  in- 
volved. Along  with  atrophy,  weakness  of  the  muscles  will 
be  observed.  The  electrical  reactions  are  normal  or  quanti- 
tatively decreased.  Mechanical  irritability  may  be  increased 
in  the  affected  muscles,  so  that  if  the  thigh-muscles  are 
affected  the  knee-jerk  is  increased.  Sensory  symptoms  are 
absent. 

Pathology :  The  muscle-fibres  are  not  degenerated,  but  are 
narrowed,  paler,  and  more  flaccid.  The  nuclei  may  be  in- 
creased. The  condition  is  probably  a  reflex  one,  dependent 
upon  irritation  of  the  articular  nerve-ending,  which  is  centrip- 
etally  propagated  to  the  cells  of  the  anterior  horns  which 
give  origin  to  the  motor  nerves.  The  change  in  these  cells 
is  a  molecular  one. 

Diagnosis :  The  occurrence  of  atrophy  following  inflamma- 
tion in  a  joint  is  characteristic.  From  nerve-injury  follow- 
ing dislocation  the  arthritic  atrophy  is  distinguished  by  the 
history,  the  absence  of  changes  in  the  electrical  reactions  and 
of  nerve  tenderness.  Changes  and  adhesions  in  joints  some- 
times occur  secondarily  to  neuritis ;  in  these,  however,  the 
atrophy  precedes  the  joint-trouble,  and  other  evidences  of 
neuritis  are  present.  The  early  stage  of  progressive  muscu- 
lar atrophy  might  also  be  confounded  with  it.  In  such  a  case, 
it  might  be  necessary  to  await  for  a  time  the  development  of 
the  disease  before  giving  a  positive  opinion. 

The  treatment  consists  in  the  relief  of  the  inflammation  of 
the  joint  and  the  employment  of  electricity,  massage,  and 
strychnine. 

Progressive  Neurotic  Muscular  Atrophy. 

Etiology  :  This  form  of  atrophy,  also  known  as  either  the 
peroneal  type  of  progressive  muscular  atrophy,  progressive 
neurotic  atrophy,  or  ]irogressive  neural  muscular  atrophy,  is 
a  form  of  atrophy  beginning  in  the  intrinsic  muscles  of  the 
feet  and  extending  upward.     It  may  make  its  appearance  at 


218  SYSTE3r  DISEASES. 

any  period  between  infancy  and  late  in  life,  but  usually  does 
so  before  the  twentieth  year.  It  is  more  common  in  males 
than  females.  It  is  a  hereditary  or  family  disease  ;  no  other 
cause  is  known. 

Symptoms  :  The  small  muscles  of  the  foot  are  usually  at- 
tacked first,  then  the  disease  spreads  to  the  peronei,  extensor 
communis  digitorum,  and  tibialis  anticus.  The  weakening 
of  these  muscles  causes  club-foot,  at  first  talipes  cavus,  which 
later  develops  into  pes  equinus  or  equino-varus.  The  mus- 
cles of  the  calf  then  suffer,  then  those  of  the  thigh,  especially 
the  vastus  internus.  About  this  time  the  small  muscles  of 
the  hand  become  atrophied  as  in  progressive  muscular  atro- 
phy, then  the  forearm  muscles.  The  muscles  of  the  upper 
arm,  neck,  face,  and  body  but  rarely  become  affected.  Fibril- 
lary twitchings  are  seen  in  the  affected  muscles.  The  deep 
reflexes  are  abolished  as  the  disease  advances.  Changes  in 
the  electrical  reactions  occur  early — first  a  quantitative  dis- 
ease, then  a  DeE.  being  found. 

Vague  pains  and  paresthesias  are  often  present,  and  dimin- 
ished sensibility  is  found  in  some  cases.  The  affected  limbs 
are  apt  to  be  cyanotic  and  cold.  Both  limbs  are,  in  most 
cases,  affected,  but  the  process  may  be  confined  to  one.  Very 
rarely  it  may  begin  in  the  hands.  The  disease  appears  to 
occupy  an  intermediary  position  between  progressive  muscu- 
lar atrophy  and  the  muscular  dystrophies. 

Morbid  anatomy :  There  have  been  found  degeneration  of 
the  nerve-fibres,  excess  of  connective  tissue  with  proliferation 
of  cells  in  the  neurilemma  ;  usually  also  degeneration  of  the 
posterior  roots,  with  ascending  degeneration  in  the  posterior 
columns  and  changes  in  the  ganglion-cells  of  the  gray  matter. 

Progressive  neurotic  atrophy — diagnosis:  The  disease  may  be 
confounded  with  progressive  muscular  atrophy  and  multiple 
neuritis.  From  the  first  it  differs  in  the  mode  of  onset,  the 
age  of  the  patient,  and  possible  existence  of  a  history  of 
heredity,  and  the  presence  of  sensory  symptoms  and  qualita- 
tive changes  in  the  electrical  reactions. 

From  multiple  neuritis  it  differs  in  its  mode  of  onset, 
method  of  progression,  and  the  absence  of  nerve  tenderness. 

The  prognosis  as  regards  cure  is  bad,  but  the  progress  may 
be  slow. 


THE  MUSCULAR  DYSTROPHIES.  219 

Treatment  consists  of  toni('s,  the  use  of  electricity  and 
massage,  and  to  promote  the  nutrition  of  the  muscles.  Re- 
sulting deformities  may  be  helped  by  tenotomy  and  braces. 

The  Muscular  Dystrophies. 

Definition :  These  are  hereditary  aiFeetions  characterized  by 
progressive  muscular  wasting  beginning  in  certain  groups  of 
muscles,  which  is  sometimes  preceded  by  hypertrophy  ;  some- 
times associated  with  hypertrophy  of  other  muscles,  and  de- 
pendent on  changes  in  the  peripheral  motor  neurons,  most 
marked  in  their  intra-muscular  endings. 

Muscular  dystrophies — etiology :  The  only  etiological  factor 
known  is  the  influence  of  heredity,  the  disease  occurring  in 
several  generations.  The  disease  usually  sets  in  before 
puberty,  but  may  appear  later. 

Symptoms :  A  number  of  different  clinical  types  of  mus- 
cular dystrophies  have  been  described  dependent  upon  the 
age  at  the  onset,  muscles  first  affected,  the  occurrence  of  hyper- 
trophy, etc. 
They  are  : 

I.  Pseudo-muscular  hypertrophy, 
II.  Landouzy-Dejerine  type,  or  infantile  progressive  mus- 
cular atrophy  of  Duchenne,  or    facio-scapulo-hu- 
meral  type  which  appears  in  young  children ;  the 
facial  muscles  are  first  involved. 
III.  Erb's  juvenile  type  or  scapulo-humeral  type,  appear- 
ing in  late  childhood  or  youth,  and  beginning  in 
the  muscles  about  the  shoulder. 
There  is  no  sharp  line  of  division  between  these  types. 
Each  of  the  different  types  may  occur  in  the  same  family, 
and  the  peculiar  characteristics  of  one  type  may  be  present 
in   another.     In  all  of  these   forms    sensory  symptoms   are 
absent ;  there  are  no  fibrillary  tremors  ;  the  DeR  is  usually 
absent,  and  the  deep  reflexes  that  are  connected  with  affected 
muscles  are  absent.     The  parts  are  cold  and  cyanosed,  and 
the  intelligence   is  good.     Deformities  often   develop.     The 
peculiarities  of  each  type  will  be  described  separately. 

Pseudo-muscular  hypertrophy :  This  form  usually  appears 
under  the  age  of  ten.     Weakness  is  first  noticed  in  the  legs, 


220 


SYSTEM  DISEASES. 
Fig.  39. 


Pseudo-muscular  hypertrophy  in  brothers  (Infirmary  for  Nervous  Diseases, 
Philadelphia). 

shown  by  clumsincs.'^  and  a  tendcncv  to  fall,  and  a  waddling 
gait.     Difficulty  in  rising  when  seated  on  the  floor  to  an  erect 


THE  MUSCULAR  DYSTROPHIES.  221 


position  is  an  early  syni]:)toiii.  The  patient  accomplishes  this 
by  first  getting  into  a  iK)sition  similar  to  that  assumed  in 
playing  leap-frog.  Pie  then  raises  the  body  by  climbing  iij) 
his  legs  with  his  hands.  Shortly  after  this  the  calves  will 
be  found  to  feel  tirni  to  the  touch.  The  hypertro[)hy  may 
not  extend  beyond  this,  or  it  may  increase  and  the  legs  as- 
sume huge  pro[)ortions.  The  extensors  of  the  leg,  glutei, 
lumbar  muscles,  deltoids,  triceps,  and  infraspinati  in  the  order 
given,  next  become  hypertrophied.  The  attitude  when  erect 
is  characteristic :  the  legs  are  far  apart,  the  back  curved, 
the  shoulders  thrown  back,  and  the  abdomen  protruded  (Fig. 
39).  The  latissimus  dorsi,  lower  part  of  the  pectorals,  upper 
arm,  and  thigh  muscles  usually  become  atrophied.  After  a 
time  the  hypertrophy  may  disappear  and  be  succeeded  by 
atrophy. 

Facio-scapulo-humeral  type  :  This  type  begins  usually  about 
the  third  or  fourth  year.  Atrophy  first  attacks  the  face,  giv- 
ing it  a  peculiar  appearance  ;  weakness  of  the  orbicularis  oris 
causes  the  lips  to  protrude,  producing  the  so-called '' tapir- 
mouth."  The  eye  muscles  and  those  of  mastication  and 
deglutition  are  not  involved.  The  atrophy  then  extends  to 
the  shoulders  and  arms,  and  the  subsequent  course  is  as  in 
other  types. 

Scapulo-humeral  or  Erb's  type :  This  type  usually  appears 
later  in  life  than  the  two  preceding  types.  The  muscles  of  the 
shoulder  girdle  are  first  attacked ;  then  those  of  the  arm,  back, 
part  of  the  pectorals,  latissimus  dorsi,  trapezeii,  and,  finally, 
the  thigh  muscles.  The  forearm  and  legs  are  involved  very 
late,  if  at  all.  The  supra-  and  infraspinati  also  usually 
escape. 

Muscular  dystrophies — morbid  anatomy :  In  the  early  stages 
true  hypertrophy  of  muscle-fibres  may  be  observed.  In 
others  there  is  proliferation  of  muscle  nuclei  and  longitudinal 
splitting  of  the  fibre  ;  along  with  this  there  is  increase  of  con- 
nective tissue,  which  takes  the  place  of  the  destroyed  muscle- 
fibres.  In  the  pseudohypertrophic  form  there  is  often  a 
deposit  of  fat  in  the  connective-tissue  cells,  which  increases 
until  extensive  lipomatosis  results.  Later  this  may  l)e  ab- 
sorbed. Evidences  of  deg(Mieratiori  have  been  found  in  the 
cord  and  nerves,  but  usually  they  ar(!  noi-mal  in  a])])earance. 


222  SYSTEM  DISEASES. 

Diagnosis :  The  peculiar  features  above  described  should 
enable  a  diagnosis  to  be  made  without  difficulty.  Progressive 
muscular  atrophy,  progressive  neurotic  atrophy,  and  multiple 
neuritis  are  the  only  alFections  that  could  be  confounded  with 
them. 

Prognosis  :  There  is  no  cure  known.  Their  progress,  how- 
ever, is  usually  slow,  and  patients  may  live  twenty-five  or 
thirty  years. 

Muscular  dystrophies — treatment :  A  mother  who  is  a  mem- 
ber of  a  dystrophic  family  should  not  suckle  her  children. 
Infants  born  of  such  parents  should  have  the  best  of  hygienic 
care  and  surroundings.  Tonics  of  all  sorts,  especially  strych- 
nine, are  indicated.  Massage  and  electricity  may  be  em- 
ployed. Much  benefit  has  been  derived  from  systematic  but 
gentle  gymnastic  exercises.  For  the  contractures  which  may 
result  tenotomies  may  prove  useful. 


DISEASES  AFFECTING  BOTH  CENTRAL  AND  PERIPHERAL 
MOTOR  NEURONS. 

Progressive  Muscular  Atrophy  and  Amyotrophic  Lateral 

Sclerosis. 

Etiology :  Progressive  muscular  atrophy,  or  that  type  in 
which  the  degeneration  is  principally  confined  to  the  lower 
neuron,  is  more  common  than  amyotro'phic  lateral  sclerosis,  or 
that  form  in  which  both  neurons  are  equally  attacked.  Both 
forms  are  more  common  in  males  than  females,  and  usually 
occur  between  the  ages  of  thirty  and  fifty.  Cases  may  occur 
on  either  side  of  these  limits. 

Exposure  to  cold  and  wet,  mental  strain,  infectious  diseases, 
acute  rheumatism,  and  syphilis  have  been  mentioned  as 
causes,  but  the  connection  often  seems  to  be  on  slight 
grounds.  Chronic  lead-poisoning,  however,  is  a  well-defined 
cause  of  tiie  ]M'ogressive  muscular  atrophy  type.  The  disease 
is  not  hereditary. 

Progressive  muscular  atrophy  and  amyotrophic  lateral  scle- 
rosis— symptoms:  The  syniptduis  wlien  the  discnso  is  confined 
to  the  Idircr  uciiraii  A\ill  be  mciitidiicd  lirsl.  The  jjaliciit 
usually  ilrst  siifiers  for  a   time  iVom    riieuniatic  ])ains  in   llic 


PROGRESSIVE  MUSCULAR  ATROPHY.  223 

shoulder  and  hand.  A  feeling  of  numbness  and  weariness 
may  also  be  complained  of.  Muscular  wasting  is  usually 
noticed  in  one  hand,  especially  in  the  muscles  su])plied  by  the 
ulnar  nerve,  the  adductor  pollicis  being  usually  first  affected. 
Other  muscles  of  the  ball  of  the  thumb,  the  lumbricales,  and 
interossei  soon  follow,  leaving  depressions  between  the  meta- 
carpal bones.  As  the  atrophy  becomes  more  intense  the  claw- 
hand  described  on  p.  157  is  produced.  The  atrophy  gradu- 
ally extends  up  the  arm  to  the  shoulder,  during  which  time, 
a  period  of  from  three  to  nine  mouths,  atrophy  will  probably 
also  have  begun  in  the  other  hand.  If  the  disease  continues 
to  spread,  the  muscles  of  the  back  and  intercostals  are  next 
attacked  ;  then  the  muscles  of  the  hip  and  thigh,  the  glutei, 
abductors,  and  extensors  of  the  leg  being  most  often  affected. 
The  muscles  below  the  knee  may  be  next  involved,  but  they 
usually  escape.  Sometimes  the  process  begins  in  the  muscles 
about  the  shoulder  (upper-arm  type),  instead  of  in  the  hand, 
to  which  it  afterward  extends.  The  disease  may  also  ascend, 
causing  paralysis  of  the  diaphragm,  and  finally  reaching  the 
nuclei  in  the  medulla  (bulbar  palsy). 

The  muscles  as  they  atrophy  become  Aveak ;  but  atro- 
phy is  noticed  before  the  weakness,  and  does  not  precede  it, 
as  in  diseases  of  the  nerve-trunks.  Fibrillary  contractions 
of  the  muscles  are  marked,  even  in  muscles  that  are  not  yet 
wasted.  In  this  form  the  muscles  are  flaccid  and  the  deep 
reflexes  are  usually  absent ;  but  cases  occur  in  which  they  are 
present  or  increased.  Excepting  late  in  the  disease,  the  DeR 
cannot  be  obtained  ;  but  there  is  quantitative  decrease  in  the 
response  of  the  muscles  to  both  the  faradic  and  galvanic  cur- 
rents. 

There  is  no  anaesthesia,  but  the  dull  pains  and  parsesthesia, 
which  are  present  early,  may  continue. 

Vasomotor  disturbance,  shown  by  excessive  sweating  and 
congestion,  may  be  present  in  the  affected  parts.  The  sphinc- 
ters are  not  attacked. 

Owing  to  the  lack  of  muscle  support  deformities  may  occur 
— viz.,  lordosis,  due  to  weakness  of  the  back-nuiscles.  The 
head  cannot  be  held  erect  from  lack  of  support,  and  contract- 
ures and  partial  dislocations  are  often  observed. 

When  tbe  upper   iietiron  is  also  affected  a  diil'erent  jticture 


224  S¥STE3r  DISEASES. 

is  presented.  The  disease  may  begin  with  symptoms  of 
bulbar  palsy,  or  these  symptoms  may  not  occur  until  later. 
Then,  or  it  may  be  the  lirst  symptom,  stiffness  of  the  arms, 
followed  by  muscular  atrophy,  will  be  noticed  ;  the  legs  next 
become  similarly  affected.  The  muscles  are  atrophied  but 
spastic,  the  deep  reflexes  are  greatly  increased,  the  gait  more 
or  less  resembles  that  of  spastic  paraplegia.  The  sphincters 
are  not  affected,  but  sexual  power  is  lost.  In  the  final  stage 
dementia  may  occur. 

Progressive  muscular  atrophy  and  amyotrophic  lateral  scle- 
rosis— morbid  anatomy:  Tlie  principal  anatomical  change  is  a 
slow  degeneration  of  the  cells  in  the  anterior  horns  of  the 
cord ;  and,  if  bulbar  symptoms  are  present,  in  the  nuclei  of 
the  motor  cranial  nerves.  The  degeneration  usually  com- 
mences in  the  cells  situated  in  the  lower  cervical  and  upper 
dorsal  regions,  and  is  accompanied  by  increase  of  the  neurog- 
lia and  degeneration  of  the  fibres  forming  the  peripheral 
nerves  and  their  intra-muscular  endings.  Associated  with 
degeneration  of  the  cells,  there  are  degeneration  and  conse- 
quent atrophy  of  the  muscle-fibres.  Sooner  or  later  the  upper 
neurons  also  become  affected  ;  this  may  consist  of  slight  de- 
generation of  the  pyramidal  tracts  extending  toward  the  brain, 
or  the  entire  tract  from  the  cortical  cells  downward  may  be 
involved.  It  is  when  this  latter  change  occurs,  previous  to 
or  simultaneously  with  the  degeneration  of  the  lower  neuron, 
that  the  symptom-group  termed  amyotrophic  lateral  sclerosis 
is  produced. 

Diagnosis :  Progressive  muscular  atrophy  is  distinguished 
from  the  hereditary  dystrophies  and  progressive  neurotic 
atrophy  by  its  beginning  in  adult  life  ;  the  muscles  of  the 
hand  being  affected  first ;  the  occurrence  of  fibrillary  con- 
tractions; and  the  absence  of  similar  diseases  in  the  family. 
From  neuritis,  by  the  absence  of  pain  and  tenderness  over 
the  nerve-trunks,  and  the  fact  that  atrophy  precedes  weak- 
ness. From  syringomyelia,  by  tlie  absence  of  the  peculiar 
sensory  disturbances  and  trophic  changes  which  occur  in  that 
disease. 

Amyotrophic  lateral  sclerosis  can  be  distinguished  from  pri- 
mary spastic  ])aralysis  by  the  muscular  wasting  and  the  fact 
that  it  begins  either  in   the  arms  oi-  with   bulbar  syni])toms. 


ATAXIC  PARAPLEGIA.  225 

From  transverse  myelifis,  by  the  absence  of  anaesthesia  or 
involvement  of  the  spliineters. 

The  prognosis  as  regards  recovery  is  bad,  but  the  disease 
may  last  for  years  before  death  ensues  from  bulbar  involve- 
ment or  lung  disease,  liemissions  may  occur,  and  sometimes 
its  progress  is  permanently  arrested. 

The  treatment  consists  of  rest,  quiet,  plenty  of  fresh  air, 
and  good  feeding.  Strychnine  in  full  doses,  preferably  hypo- 
dermatically  into  the  affected  parts,  along  witii  arsenic,  jihos- 
phorus,  cod-liver  oil,  and  other  tonics  arc  indicated.  Elec- 
tricity, in  the  form  of  galvanization  to  the  s])iiie  and  the 
cathode  applied  labile  to  the  muscles,  ma}-  be  of  service. 

COMBINED  SYSTEM  DISEASES. 

When  the  disease  affects  both  afferent  and  ef event  systems  of 
neurons  it  is  called  a  combhied  system  disruse.  While  it  is 
convenient  to  describe  under  this  head  the  diseases  which 
follow  below,  it  should  be  remembered  that  it  is  denied  by 
some  that  these  are  true  system  diseases,  but  are  diffuse 
processes ;  also  that  in  locomotor  ataxia  lesions  in  the  motor 
neurons  may  occur,  and  that  in  diseases  primarily  affecting 
motor  neurons  changes  may  be  found  in  the  posterior  col- 
umns. This  is  the  exception  and  not  the  rule.  In  the  dis- 
eases about  to  be  described  the  symptoms  from  the  first  point 
to  involvement  of  both  motor  and  sensory  neurons. 

Ataxic  Paraplegia. 

Definition :  This  is  a  disease  presenting  a  combination  of 
thc'Symptoms  of  spastic  paraplegia  and  locomotor  ataxia. 

Etiology :  It  is  due  to  disease  of  the  posterior  and  lateral 
columns.  The  disease  is  most  common  in  males  between 
thirty  and  forty  years  of  age,  but  may  appear  either  earlier 
or  later.  A  history  of  syphilis  is  rare.  Exposure  to  cold, 
traumatism,  and  sexual  excess  have  appeared  to  act  as  causes. 
In  many  cases  no  cause  can  be  traced. 

Ataxic  paraplegia — symptoms:  The  onset  is  usually  gradual, 
l)ut  may  be  rapid.  The  patient  first  notices  that  he  tires 
easily,  and  that  in   turning  suddenly  there   is  a  tendency  to 


226  SYSTEM  DISEASES. 

fall.  Difficulty  may  be  experienced  in  walking  in  the  dark. 
The  Romberg  symptom  is  present,  and  the  tests  employed 
to  detect  incoordination  reveal  its  presence  in  the  legs  and 
at  times  also  in  the  arms.  The  gait  is  different  from  that 
of  tabes,  being  equally  unsteady  ;  but  the  feet  are  neither 
raised  so  high  nor  do  they  descend  to  the  ground  so  suddenly 
as  is  seen  in  that  disease.  Muscle-sense  is  usually  affected  as 
in  tabes. 

The  lightning-pains  of  tabes  are  absent.  Dull  pain  in 
the  sacral  region  or  higher  up  is  usually  complained  of.  Gir- 
dle-pain is  rare.  Sensation  is  commonly  not  impaired.  Vis- 
ceral crises  are  unknown.  The  skin-reflexes  may  be  increased, 
normal,  or  diminished.  The  knee-jerk  is  much  increased  and 
ankle-clonus  can  frequently  be  obtained.  When  the  arms 
are  affected  a  similar  condition  of  reflexes  is  observed. 

Sexual  power  is  lost  early  and  tlie  sphincters  are  often  im- 
paired ;  sometimes  there  is  inability  to  empty  the  bladder. 

Eye-symptoms,  either  of  the  muscles  or  nerve,  are  usually 
absent.  As  the  disease  advances  the  ataxic  symptoms  become 
overshadowed  by  those  of  spastic  paraplegia,  but  evidences 
of  inco5rdination  can  be  found  if  looked  for. 

Late  in  the  disease,  mental  symptoms  similar  to  those  of 
paretic  dementia  may  develop. 

Morbid  anatomy :  There  is  degeneration  of  the  posterior 
columns,  which  differs  from  that  found  in  tabes  in  the  fact 
that  the  dorsal  and  lumbar  regions  suffer  equally,  or  the  dor- 
sal may  suffer  more  than  the  lumbar,  and  the  posterior  root- 
zone  in  the  postero-external  column  (Burdach's)  is  also  less 
involved.  In  the  lateral  columns  the  degeneration  chiefly 
involves  the  pyramidal  tracts,  but  frequently  the  lateral  lim- 
iting layers  and  direct  cerebellar  tracts  may  be  involved.  The 
direct  pyramidal  tracts  are  also  diseased. 

Diagnosis  :  The  disease  can  be  distinguished  from  tabes  by 
the  preservation  of  the  knee-jerks,  existence  of  ankle-clonus, 
difference  in  gait,  and  absence  of  lightning-pains  and  eye- 
symptoms  ;  from  spastic  paraplegia,  by  the  unsteadiness  of 
the  gait.  Friedreich's  ataxia  differs  in  the  early  onset,  its 
family  character,  existence  of  disordered  speech,  nystagmus, 
scoliosis,  and  talipes.  In  hereditary  cerebellar  ataxia,  nys- 
tagmus and  other  eye-symptoms  are  present.     The  disease  is 


FRIEDREICH'S  ATAXIA,  227 

hereditary  and  the  speech  is  affected.  The  features  which  dis- 
tinguish ataxic  paraplegia  from  combined  sclerosis  (Putnam's 
type,  or  that  due  to  pernicious  anaemia)  are  given  on  p.  231. 

In  cerebellar  tumors  some  or  all  of  the  general  symptoms 
of  tumor — l.  e.,  optic  neuritis,  nausea,  headache,  etc. — would 
be  present.  Syphilis  of  the  cord  (Erb's  type)  resembles 
ataxic  paraplegia,  but  differs  in  the  history  of  previous  syph- 
ilitic infection ;  the  early  and  greater  involvement  of  the 
sphincters,  and  the  frequent  good  results  from  specific  treat- 
ment. Myelitis — diffuse,  focal,  or  chronic — may  be  difficult 
to  distinguish.  In  myelitis  the  course  is  usually  more  rapid  ; 
sensory  symptoms  (pain  or  anaesthesia)  are  more  apt  to  be 
present,  and  there  is  a  regressive  instead  of  a  progressive 
tendency. 

Prognosis :  The  disease  lasts  a  long  time ;  may  become  ar- 
rested, but  is  never  cured. 

The  general  treatment  is  that  of  primary  spastic  paralysis. 
Frankel's  method  of  muscle-education  (p.  72)  may  be  tried 
for  the  incoordination. 

Hereditary  Ataxia. 

This  affection  may  be  divided  into  two  types — i.  e.,  Fried- 
reich's disease,  in  which  the  lesions  begin  and  are  most 
marked  in  the  cord;  and  hereditary  cerebellar  ataxia,  in 
which  the  cerebellum  is  first  involved. 

Friedreich's  Ataxia. 

Etiology  :  This  disease,  also  known  as  Friedreich's  disease, 
is  a  family  disease  ;  as  many  as  ten  cases  in  three  generations 
of  a  single  family  have  been  reported.  The  parents  may  be 
perfectly  healthy,  but  usually  there  is  some  degenerative  ten- 
dency in  some  of  the  ancestors,  as  alcoholism,  epilepsy,  cho- 
rea, and  syphilis.  Isolated  cases  occur.  The  symptoms  fre- 
quently appear  after  some  infectious  disease.  The  symptoms 
usually  develop  between  tlie  ages  of  six  and  fifteen. 

Friedreich's  ataxia — symptoms  :  Usually  the  first  symptom 
uoticed  is  a  gradually  developing  incoordination,  first  in  the 
legs  and  later  in  the  arms.  The  gait  is  swaying,  and  resem- 
bles the  gait  due  to  cerebellar  disease  more  than  that  of  tabes. 


228  SYSTEM  DISEASES. 

In  standing  the  legs  are  kept  wide  apart ;  the  Romberg  symp- 
tom is  usually  present,  but  may  be  absent.  Movements  of 
the  arms  are  choreiform  and  irregular.  In  making  voluntary 
movements  the  action  is  overdone,  and  when  attempting  to 
grasp  an  object  the  hand  is  held  over  it,  moving  about  it  for 
a  moment  and  then  pouncing  upon  it  as  an  eagle  upon  its 
prey  ("  hovering  hand  ").  In  many  cases,  when  the  body  is 
erect  or  the  limb  extended,  there  are  irregular  oscillating 
movements  of  the  head,  trunk,  and  extended  limb  (static 
ataxia).  After  a  while  the  speech  is  affected,  consisting  of 
the  elision  of  letters  and  sentences  and  a  hesitancy  in  the 
enunciation  of  sentences.  The  knee-jei-ks  are  in  most  cases 
lost  early.  The  skin-reflexes  are  normal.  Atrophy  of  the 
optic  nerve  and  paralyses  of  the  ocular  muscles  are  never 
seen,  but  nydagmus,  developed  usually  by  movement  of  the 
eyes  upward  or  laterally,  is  present. 

Sensory  symptoms  seldom  occur,  and  trophic  lesions  are 
rare.  Involvement  of  the  sphincters  and  mental  symptoms 
are  also  absent  until  late  in  the  course  of  the  disease.  The 
face  early  becomes  dull  and  expressionless  ;  the  mouth  is  often 
kept  partly  open.  In  the  later  stages  weakness  increases, 
some  wasting  of  the  muscles  may  occur,  and  talipes  equinus 
or  varus  and  lateral  spinal  curvature  develop. 

Friedreich's  ataxia — morbid  anatomy :  The  changes  found 
consist  of  sclerosis  of  the  posterior  and  lateral  columns  of 
the  cord.  The  posterior  roots  are  also  involved.  The  cells 
of  Clarke's  vesicular  column  and  the  direct  cerebellar  tracts 
also  suffer.  Changes  in  the  ganglion-cells  of  the  anterior 
horns  and  atrophic  changes  in  the  post-pyramidal  nucleus 
and  restiform  bodies  have  also  been  observed  ;  and  lesions  of 
the  cerebellum  have  been  reported  in  a  few  cases.  The 
change  in  this  disease  is  a  neuroglia-sclerosis  (gliosis),  and  not 
the  ordinary  connective-tissue  sclerosis.  It  is  probable  that 
the  disorder  is  a  manifestation  of  a  lower  vitality  than  normal 
of  the  affected  parts,  so  that  they  degenerate  early  in  life. 

Friedreich's  ataxia — diagnosis :  The  features  which  distin- 
guish this  from  the  cerebellar  type  will  be  made  evident  by 
a  study  of  the  symptoms  of  that  type  (p.  229). 

From  locomotor  edaxia  it  differs  in  the  early  onset,  absence 
of  pupillary  symptoms,  presence  of  nystagmus,  and  speech- 


HEREDITARY  CEREBELLAR  ATAXIA.  229 

defects ;  muscular  weakness,  deformities,  and  the  differences 
in  the  gait.  From  ataxic  paraplegia  it  is  distinguished  by 
the  later  appearance  of  symptoms,  increased  knee-jerks,  and 
absence  of  nystagmus,  which  are  features  of  that  disease. 

In  disseminated  sclerosis  the  knee-jerks  are  increased  ;  the 
speech  of  a  sing-song  or  scanning  type,  instead  of  hesitating ; 
there  are  often  optic  atrophy  and  paralysis  of  ocular  muscles  ; 
and  it  is  not  a  family  disease.  In  some  cases,  however,  the 
diagnosis  may  be  difficult.  In  cerebellar  tumor  the  general 
symptoms  of  brain-tumor  are  present,  and  choreiform  and 
ataxic  movements  of  the  arms  do  not  occur.  From  chorea 
it  is  distinguished  by  its  progressing  character,  absence  of 
knee-jerks,  absence  of  affection  of  the  face,  and  the  difference 
in  the  character  of  the  movements.  Huntingdon's  chorea, 
while  a  family  disease,  begins  in  adult  life,  and  mental  symp- 
toms soon  appear. 

Prognosis :  The  affection  is  incurable,  but  lasts  for  many 
years,  death  occurring  from  an  intercurrent  disorder. 

The  treatment  is  symptomatic,  and  consists  principally  of 
tonics,  nutrients,  and  good  hygiene.  Either  arsenic  or  nitrate 
of  silver  may  be  tried.  If  the  inheritance  is  from  the 
mother's  side,  children  should  not  be  nursed  by  her. 

Hereditary  Cerebellar  Ataxia  (of  Marie  and  Nonne). 

Etiology :  The  etiology  is  similar  to  that  of  Friedreich's 
ataxia. 

Symptoms  :  The  family  history,  cerebellar  gait,  Romberg's 
symptom,  tremor  of  the  head  and  extremities,  choreiform, 
awkward  movements  of  the  arms  and  hands,  disordered 
speech,  and  nystagmus  are  symptoms  common  to  both  this 
type  and  Friedreich's.  It  differs  in  the  usually  later  onset 
(puberty  or  later),  the  presence  of  increased  or  normal  knee- 
jerks,  and  ocular  symptoms — viz.,  Argyll-Robertson  pupil, 
diplopia,  color-blindness,  and  atrophy  of  the  optic  nerve. 
There  may  also  be  disturbances  of  sensation.  Talipes  and 
scoliosis  do  not  occur  in  this  type. 

Morbid  anatomy :  Atrophy  of  the  cerebellum  has  been 
found  in  some  cases.  In  others  there  were  no  changes  visible 
to  the  naked  eye  ;  but  by  the  use  of  the  microscope  the  cells 


230  SYSTEM  DISEASES. 

of  Purkinje  were  found  atrophied.  In  a  case  recently  re- 
ported by  Sanger  Brown  and  Myer  no  changes  were  found  in 
the  cerebellum,  but  the  tracts  in  the  cord  connected  with  its 
functions  showed  a  condition  of  defective  development. 

Hereditary  cerebellar  ataxia — diagnosis — ^prognosis — treat- 
ment :  These  are  practically  the  same  as  those  of  Friedreich's 
type.  In  this  form,  however,  the  distinction  from  dissemi- 
nated sclerosis  is  often  very  difficult. 

Combined  Sclerosis  of  the  Spinal  Cord  (Putnam's  Type 
and  that  of  Pernicious  Anaemia). 

Etiology :  This  aifection  occurs  in  persons  past  middle  life, 
and  is  associated  with  a  cachexia,  and  sometimes  with  per- 
nicious anaemia  and  other  toxsemic  conditions,  as  influenza, 
chronic  diarrhoea,  lead-poisoning,  and  malaria.  There  is  fre- 
quently a  previous  neuropathic  personal  or  family  history. 
Cases  developing  in  the  course  of  anaemia  were  first  described 
by  Lichtheim  in  1877  ;  those  produced  by  other  causes,  by 
Putnam,  and  a  little  later  by  Dana  in  1891. 

Combined  sclerosis — symptoms :  The  initial  symptom  is  a 
persistent  parsesthesia,  most  commonly  of  the  feet  (with  this 
there  is  some  weakness),  and  a  little  later  ataxia.  Pain  in 
the  back  and  limbs  may  be  present  at  this  time.  At  first 
there  are  increased  knee-jerks,  ankle-clonus,  and  some  spas- 
ticity of  the  muscles.  Late  in  the  disease  the  rigidity  may 
disappear  and  the  knee-jerks  be  lost.  After  a  few  months 
the  arms  become  affected,  the  symptoms  developing  similarly 
to  those  of  the  legs.  Parely  the  trouble  begins  in  the  arms. 
Loss  of  tactile,  pain,  and  thermic  senses  may  be  a  late  symp- 
tom ;  or  there  may  be  dissociation  of  sensation,  as  in  syringo- 
myelia. The  sphincters  are  usually  intact  until  near  the  end. 
A  slight  grade  of  dementia  may  develop. 

Morbid  anatomy :  The  posterior  columns  are  first  and  most 
involved  ;  in  some  of  the  cases  associated  with  pernicious 
anaemia  these  were  the  only  parts  involved.  In  most  cases 
the  lateral  columns,  especially  the  crossed  pyramidal  tracts, 
are  also  affected.  The  other  columns  may  be  involved,  but 
not  so  constantly  nor  completely.  Late  in  the  course  of  the 
disease    the    anterior   horns   are   attacked.      There   may  be 


COMBINED  SCLEROSIS  OF  THE  SPINAL  CORD.      231 

softening  of  the  cord  with  the  production  of  cavities.  The 
bloodvessels  are  affected  with  hyaline  degeneration. 

The  nature  of  the  process  is  a  prinuiry  nerve-fibre  degen- 
eration due  to  the  action  of  the  poison. 

Combined  sclerosis — diagnosis :  The  disease  is  distinguished 
from  locomotor  ataxia  by  its  rapid  onset,  motor  weakness, 
absence  of  ocular  symptoms,  increased  knee-jerks  (early 
stage),  and  the  coexisting  anaemia. 

From  ataxic  paraplegia,  by  its  rapid  development  and 
progress,  the  greater  degree  of  weakness,  and  constitutional 
symptoms. 

From  multiple  neuritis,  by  the  absence  of  pain,  tenderness, 
and  marked  muscular  atrophy.  Those  cases  in  which  disso- 
ciation of  sensation  occurs  may  be  mistaken  for  syringo- 
myelia, but  the  rapid  development  of  the  symptoms  will  in 
a  short  while  distinguish  the  two. 

The  prognosis  is  not  good.  Death  may  occur  in  from  six 
months  to  three  years.     Some  cases  recover. 

The  treatment  consists  of  arsenic,  iron,  quinine,  and  other 
tonics  and  nutrients. 


CHAPTER   XL 


DIFFUSE  AND  LOCAL  DISEASES  OF  THE   BRAIN. 

CEREBRAL  LOCALIZATION. 

Reference  to  Figs.  40-45  will  indicate  the  location  and 
names  of  the  various  convolutions,  sulci,  and  lobes  of  the 
brain,  a  knowledge  of  which  is  essential  to  the  location  of  a 
lesion  involving  the  cortical  centres. 

In  determining  the  locality  of  a  lesion  in  the  brain  it  must 


Fig.  40. 


Praecentral  F. 


.F.Rolando 


Parietal  K. 


1st  Frontal  F. 


Parieto-Occipiial  F. 


2nd  FrontaVF. 


F.Sylvius 
1st  TemporaUF. 

Convolutions  of  the  left  hemisphere. 


?nd  Temporal F. 


be  remembered  that  symptoms  referable  to  those  centres  in 
which  the  lesion  is  actually  situated  are  not  the  only  symp- 
toms that  may  be  present,  but  that  others,  either  irritative 
or  paralytic,  are  usually  present,  due  to  irritation  or  com- 
pression of  neighboring  centres  or  tracts. 

232 


CEREBRAL  LOCALIZATION. 
Fig.  41. 


233 


Int.  Capsule\ 


Caudate-Nucleus 
(Bead )  ) 


Jst  Frontal/. 

2nd  Frontal/. 


Caudate  NucleuS 
(.Tail) 


Optic  Badiations 

J'ulvinar 


Parietal/. 


Cuneus       P<^'-'<'to-occfpital  f. 


Convolutions  of  the  vertex, on  the  right;  on  the  left,  the  basal  ganglia,  internal 
capsule,  centrum  ovale,  and  cuneus. 


Fig.  42. 


Farieto-occipital  f. 


Calloso-onargindl  /. 


Calcarine  /. 


Mnmmilhirii  Body"        i  Optic  Tract 

Anterior  Commissure 

Vertical  section  through  the  centre  of  the  corpus  callosum,  showing  tlie  convolu- 
tions of  the  inturned  surfaces  of  the  hemispheres. 


234  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BBAIN. 

The  prefrontal  region :  That  portion  of  the  frontal  lobes 
situated  in  front  of  the  ascending  and  third  frontal  convolu- 
tions constitutes  the  iwefontal  region.  Here  are  thought  to 
be  located  the  higher  psychical  centres,  those  which  have  to 
do  with  the  higher  mental  processes — viz.,  memory,  attention, 
judgment,  reasoning,  and  comparison.    According  to  Bianchi, 

Fig.  43. 
Olfactory  bulbs 

4 


Convolutions  of  the  base  of  the  cerebrum  and  the  cerebellum. 


it  is  that  part  of  the  brain  Avhere  the  various  motor  and  sen- 
sory images  deposited  in  the  other  centres  of  the  cortex  become 
coordinated  and  fused  (an  association-centre).  In  addition, 
according  to  Munk,  the  trunk-muscles  have  their  cortical 
representation  in  this  lobe. 

Central  convolutions  :  The  cells  of  the   following  convolu- 


CENTRAL  CONVOLUTIONS. 


235 


tions — i.  €.,  the  precentral  or  ascending  central ;  the  post- 
central or  ascending  parietal ;  the  npper  portions  of  the  first 
and  second  frontal  ;  the  superior  parietal  lobide  ;  the  para- 
central lobule;  and  part  of  the  precuneus  (see  Figs.  40,  41, 
and  42) — originate  and  control  voluntary  motor  impulses. 
They  also  probably  receive  sensory  impressions ;  and  this  re- 
gion is  often  termed  the  sensori-motor  region. 

The  leg-  and  trunk-muscles  are  mainly  represented  in  the 

Fig.  44. 

0     T 


Cortical  centres  and  areas  of  representation  on  the  lateral  aspect  of  the  heml- 

cerebrnm. 

upper  portions  of  the  precentral  and  postcentral  convolutions 
and  the  paracentral  lobule.  The  muscles  of  the  arm  are  in  the 
middle  third  of  the  precentral  and  postcentral ;  while  those 
of  the  face,  larnyx,  pharynx,  and  tongue  are  in  the  loiver  por- 
tion of  these  convolutions. 

The  upper  portion  of  the  first  and  second  frontal  governs 
the  movements  of  the  head  and  eyes.  These  centres  are  not 
sharply  defined,  but  overlap  to  some  extent. 


236   DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

As  has  been  said,  these  convohitions  probably  also  receive 
sensory  impressions  from  the  skin,  muscles,  and  possibly  the 
viscera ;  and  thus  are  the  cortical  sensory  centers  for  faetile 
and  muscle  sense^  (^ig-  44). 

Destructive  lesions  involving  these  convolutions  cause  a 
■paralysis^  which  becomes  spastic  in  the  muscles  of  the  oppo- 


Cortical  centres  and  areas  of  representation  on  the  mesial  aspect  of  the  hemi- 

cerebrum. 


site  side.  It  is  not  always  complete,  as  the  lesion  may  be 
limited  to  one  or  more  centres  only,  causing,  for  instance,  a 
monoplegia  or  facial  paralysis.  Paralysis  limited  to  a  few 
muscles,  is  always  due  to  a  lesion  of  or  near  the  cortex,  when 
caused  by  a  cerebral  lesion. 

Also  muscles  which  habitually  act  together,  as  the  muscles 
of  respiration  and  the  facial  muscles  when  used  to  express 

^  The  superior  parietal  lobule  is  probably  the  location  where  sensations 
from  the  muscles  are  received. 


INTERNAL   CAPSULE.  237 

the  emotions,  are  represented  on  both  sides  of  the  cortex,  and 
a  one-sided  cerebral  lesion  does  not  cause  their  paralysis,  as 
the  other  side  of  the  brain  takes  up  the  work.  Some  dis- 
turbances of  sensation,  especially  of  the  muscular  and  stere- 
ognostic  sense,  are  often  found. 

In  irritative  lesions  of  the  cortex  there  are  either  localized 
spasms  or  spells  of  Jacksonian  epilepsy.  There  may  also  be 
jjaroesthesia  of  the  affected  parts. 

Centrum  ovale :  Lesions  in  this  part  may  involve  motor, 
sensory,  or  association  fibres  (Figs.  4—9).  A  lesion  near  the 
motor  region  of  the  cortex  causes  paralysis  resembling  in 
distribution  that  of  a  cortical  palsy  (subcortical  lesion).  Such 
lesions  do  not  cause  spasm ;  if  they  do  occur,  the  spasm  is  due 
to  the  cortex  becoming  involved,  and  the  paralysis  precedes 
the  development  of  spasm.  In  cortical  lesions  it  is  usually 
vice  versa. 

When  the  lesion  is  near  the  internal  capsule  the  paralysis 
resembles  that  due  to  a  lesion  in  that  situation.  There  may 
also  be  hemiansesthesia,  hemianopsia,  and,  if  on  the  left  side, 
aphasia. 

Corpus  callosum :  Symptoms  indicative  of  a  lesion  in  this 
situation  are  complete  or  partial  hemiplegia,  gradually  extend- 
ing to  the  opposite  side,  and  later  disturbances  of  speech,  diffi- 
culty in  deglutition,  and  dementia.  Similar  symptoms  might, 
however,  be  due  to  other  causes — viz.,  double  cortical  lesion. 

Internal  capsule :  Through  this  pass  within  a  small  space 
the  motor  and  sensory  projection-fibres,  which  pass  to  and 
from  the  cortex  (Fig.  4).  In  the  region  of  the  "  knee  "  of 
the  capsule  are  the  fibres  which  pass  from  the  cortex  to  the 
nuclei  of  the  motor  nerves  of  the  eye,  and  to  facial  and  hypo- 
glossal nerves  ;  also  those  which  pass  to  the  nuclei  of  the 
nerves  which  govern  the  other  muscles  concerned  in  speech 
(see  Anatomy,  tenth  nerve).  The  pyramidal  tract  is  next  to 
these  posteriorly,  the  fibres  controlling  arm-movements  being 
anterior  to  those  for  the  leg.  The  fibres  carrying  impulses 
concerned  in  common  sensation  and  those  of  special  sense 
(vision,  hearing,  etc.)  are  posterior  to  these  (Fig.  46).  As  the 
fibres  of  the  pyramidal  tract  are  here  in  a  compact  bundle,  a 
lesion  in  this  situation  causes  a  hemiplegia  upon  the  opposite 


238   DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

side.  Monoplegias  are  never  caused  by  a  lesion  in  this  situa- 
tion. If  the  lesion  is  in  the  hinder  part  of  the  posterior 
limb,  there  would  be  hemiansesthesia,  which  may  involve  the 
special  senses,  the  defect  of  vision  being  a  homonymous  hemi- 
anopsia.    Some  motor  paralysis  would  also  likely  be  present. 

Fig.  46. 


Diagram  of  horizontal  section  throuah  the  basal  ganglia  and  internal  capsule  (left 
side),  showing  the  position  of  the  chief  tracts  in  the  internal  capsule.  The 
region  of  the  capsule  marked  by  the  letters  L  A  Fis.  occupied  by  motor  fibres  : 
L  corresponds  to  the  leg-fibres,  A  to  the  arm-fibres,  jPto  the  face-fibres  (includ- 
ing fibres  to  face-muscles  and  tongue).  The  region  i^-C  contains  the  fronto-cere- 
bellar  tract  (intellectual  tract).  The  region  marked  S  contains  the  general 
sensory  tract  from  the  opposite  side  and  the  fibres  from  the  optic  and  olfactory 
nerves  of  the  opposite  side,  sometimes  called  the  "  sensory  crossway." 


Crus :  The  third  cranial  nerve  arises  from  the  crus  near 
the  pyramidal  tract.  A  lesion  here  would  cause  spastic  hemi- 
plegia upon  the  opposite  side  and  paralysis  of  the  muscles 
supplied  by  the  third  nerve  upon  the  same  side  (Fig.  47). 
As  the  optic  tract  crosses  the  crus,  it  may  also  be  involved, 
causing  a  homonymous  hemianopsia. 

If  the  tegmentum  is  involved  without  the  motor  tract,  dis- 
turbances of  common  and  muscular  sensibility  and  ataxia  of 
the  opposite  side  occur. 

Optic  thalamus  :  The  thalamus  is  connected  with  the  cortex 
of  the  frontal,  parietal,  occipital,  and  temporal  regions.  The 
optic  tract  and  numbers  of  sensory  fibres  from  the  cord  also 
end  in  it,  a  new  neuron,  the  thalamie-cortieo ,  the  axons  of 
which  reach  the  cortex,  beginning  there  (see  Sensory  Tract). 
The  centre  for  the  regulation  of  the  body-heat  is  thought  to 
be  there  situated.     With  the  corpora  quadrigeraina  and  ex- 


THE  PONS.  239 

ternal  geniculate  bodies  the  posterior  part  forms  the  primary 
centre  for  vision. 

The  functions  of  the  corpus  driafum  are  unknown. 

The  corpora  quadrigemina  :  The  anterior  tubercles,  togetlier 
with  the  external  geniculate  bodies,  form  part  of  what  are 
knt)wn  as  the  primary  visual  centres,  the  remaining  part  of 
these  centres  being  situated  in  the  posterior  part  of  the  optic 
thalami.  They  are  connected  with  the  optic  and  motor 
oculi  nerves,  and  control  the  reflex  movements  of  the  iris  and 
ciliary  muscles. 

The  posterior  tubercles,  together  with  the  internal  geniculate 
bodies,  are.  connected  with  the  auditory  nerves  and  cerebellum, 
and  control  reflex  movements  connected  with  hearing  and 
sensations  of  space. 

The  cerebellum :  The  gray  matter  of  the  cerebellum  is  sit- 
uated in  the  cortex  and  in  ganglionic  masses  in  its  substance; 
but  excepting  the  vermis  or  median  lobe,  which  appears  to 
control  most  of  their  functions,  the  relations  of  this  gray 
matter  to  the  cerebellar  functions  are  not  well  known.  It  is 
connected  with  the  motor  and  sensory  regions  of  both  the 
brain  and  cord  (see  Motor  and  Sensory  Tracts),  the  auditory 
nerve,  some  collections  of  nerve-cells  in  the  pons,  and  with 
the  inferior  olivary  bodies  of  the  medulla. 

The  functions  of  the  cerebellum  are  still  the  subject  of  in- 
vestigation. It  is  known  to  take  an  active  part  in  the  coor- 
dination of  muscular  movements  and  of  maintaining  our 
equilibrium  and  relations  to  surrounding  objects.  It  also 
regulates  automatic  movements.  According  to  Hnghlings 
Jackson,  its  disease  causes  paresis  of  the  trunk-muscles.  It  is 
also  thought  by  many  (Bastian  and  Hughlings  Jackson)  that 
it  is  cerebellar  influence  which  maintains  muscle-tone. 

The  pons  :  The  gray  matter  of  the  pons  consists  of  cells 
which  form  the  nuclei  or  beginning  of  the  peripheral  neurons 
of  the  sixth,  seventh,  and  motor  division  of  the  fifth  cranial 
nerves.  It  also  contains  the  ascending  or  sensory  nucleus  of 
the  fifth  nerve,  and  the  motor  and  sensory  tracts  on  their  way 
from  the  cord  to  the  cortex  pass  through  it.  There  are  other 
collections  of  nerve-cells  in  the  pons  which  are  connected 
with  the  cerebellum  and  cerebral  cortex. 


240  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

If  the  lesion  is  in  the  upper  part  of  the  pons,  where  the  fibres 
running  to  the  cranial  nerve  nuclei  have  not  yet  decussated, 
the  resulting  paralysis  would  be  similar  to  that  due  to  cere- 
bral disease. 

Fig.  47. 


Showing  the  mechanism  of  alternate  hemiplegias.  A  lesion  at  A  causes  complete 
hemiplegia  by  destroying  the  motor  tract.  One  at  M  causes  paralysis  of  third 
cranial  nerve  (motor  oculi)  by  destroying  its  nucleus  or  root  on  same  side, 
and  paralysis  of  arm  and  leg  on  opposite  side.  A  lesion  at  F  causes  facial  palsy 
on  same  side ;  hemiplegia  on  opposite  side.  In  a  lesion  at  H  the  hypoglossus 
would  be  affected  on  one  side,  with  hemiplegia  on  the  other  (modified  from 
Edinger). 


Lesions  situated  below  the  middle  of  the  pons  usually  in- 
volve the  motor  path,  with  one  or  more  of  the  cranial  nerves 


MEDULLA    OBLONGATA.  241 

mentioned  above,  causing  a  crossed  paralysis,  which,  except- 
ing when  the  third  nerve  is  involved  (see  Cms),  is  always  in- 
dicative of  a  lesion  in  the  pons  (Fig.  47).  If  situated  near 
the  middle  line,  a  lesion  may  cause  paralysis  of  one  motor 
tract  and  of  both  facial  nerves.  A  destructive  lesion  in- 
volving the  nucleus  of  the  sixth  causes  conjugate  deviation 
of  the  eyes  to  the  side  opposite  the  lesion. 

If  the  fillet  and  sensory  root  of  the  fifth  nerve  are  involved, 
hemiansesthesia  results  ;  if  below  the  upper  third  of  the  pons, 
it  is  a  crossed  paralysis,  the  anaesthesia  of  the  face  being  on 
the  same  side  as  the  lesion.  If  tlie  sensory  root  of  the  fifth 
escapes,  the  face  is  not  involved.  Bilateral  disease  may  occur, 
causing  various  combinations  of  these  symptoms. 

Paralysis  of  the  sixth  and  seventh  nerves  without  that  of 
the  auditory  indicates  a  lesion  in  the  posterior  part  of  the  pons. 

If  the  middle  cerebellar  peduncle  becomes  involved,  forced 
movements  occur.  Acute  lesions  frequently  produce  hyper- 
pyrexia and  disturbances  of  respiratory  and  cardiac  action. 

Medulla  oblongata  :  The  nuclei,  or  cells  of  the  second-order 
neurons,  of  the  cranial  nerves,  from  the  eighth  to  the  twelfth 
inclusively,  excepting  that  portion  of  the  eleventh  which 
comes  from  the  cervical  region  of  the  cord,  are  situated  in 
the  medulla  (see  Fig.  38). 

It  is  important  to  remember  that  the  medulla  and  that 
portion  of  the  pons  containing  cranial  nerve  nuclei  are  really 
portions  of  the  cord,  and  that  these  cells  are  analogous  to 
those  cells  found  in  the  gray  matter  of  the  cord  to  be  de- 
scribed, and  that  their  functions  are  similar. 

In  the  medulla  also  are  situated  the  various  reflex  and 
automatic  centres  which  control  the  circulatory  and  respira- 
tory functions,  visual  movements,  and  secretion.  The  supe- 
rior and  inferior  olivary  bodies,  masses  of  gray  matter  in  the 
medulla,  are  connected  with  the  cord,  basal  ganglia,  and 
cerebellum.  They  have  something  to  do  with  the  functions 
of  coordination  and  equilibrium. 

Lesions  high  up  may  damage  the  pyramidal  tract  above 
its  decussation  and  the  twelfth  nerve  ujion  the  same  side  as 
the  lesion  (Fig.  47). 

D/.^casr  of  the  l)u]bar  nuclei  gives  rise  to  the  characteristic 
group  of  sym|)t()ms  described  under  bulbar  palsy.  Acute 
ifi— N.  1). 


242   DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

lesions  of  the  medulla  usually  cause  death  in  a  very  short 
time. 

Chronic  lesions  involving  the  floor  of  the  fourth  ventricle, 
as  pressure  from  a  cerebellar  tumor,  sometimes  cause  either 
polyuria  or  glycosuria,  or  both. 

The  functions  of  the  occipital  lobe  are  detailed  on  p.  110, 
under  aifections  of  the  optic  tract.  The  cortical  centres  con- 
cerned in  speech  are  described  under  the  head  of  aphasia. 

APHASIA. 

Definition:  By  aphasia,  we  mean  the  partial  or  complete 
loss  of  the  power  of  expression  or  of  comprehension  of  any 
of  the  usual  signs  of  language ;  not  dependent  upon  lesions 
of  the  peripheral  nerves  or  organs,  but  upon  lesions  of  the 
cortical  centres  or  tracts  connecting  them. 

Varieties  :  Those  forms  of  aphasia  associated  with  loss  of 
power  to  comprehend  or  use  spoken  words  or  symbols  have 
been  divided  into  sensory  and  motor. 

Sensory  aphasia  is  present  when,  the  peripheral  apparatus 
being  intact,  the  patient  is  unable  to  understand  the  language 
which  he  has  been  accustomed  to  use  (word-deafness,  or 
auditory  aphasia) ;  or  is  unable  to  recognize  the  meaning  of 
the  symbols,  either  written  or  printed,  with  which  he  was 
formerly  familiar ;  in  other  words,  is  unable  to  read  (word- 
blindness,  alexia,  or  visual  aphasia). 

When  a  patient  loses  the  power  of  understanding  the  uses  of 
familiar  objects  he  is  said  to  have  apraxia.  Word-blindness, 
apraxia,  and  the  inability  to  understand  signs  are  all  subdivi- 
sions of  what  is  termed  mind-blindness — viz.,  he  sees,  but  does 
not  appreciate  what  he  sees. 

Motor  aphasia,  or,  as  it  is  sometimes  termed,  aphemia,  is 
present  wlien  the  patient,  the  peripheral  speech-apparatus 
being  intact,  is  unable,  either  completely  or  partially,  to  give 
expression  to  his  thoughts. 

Loss  of  the  power  of  writing,  not  dependent  upon  weak- 
ness of  the  arm,  is  called  agraphia ;  it  is  practically  always, 
M^ien  })resent,  associated  with  either  aphemia  or  word- 
blindness. 


APHASIA.  243 

Loss  of  the  power  of  understanding  or  employing  gesture 
or  pantomime  is  termed  amimia.  Infrequently,  either  with 
or  without  defects  of  ordinary  speech,  there  is  loss  of  the 
power  to  produce  or  comprehend  musical  sounds ;  this  defect 
is  termed  amusia. 

In  some  cases  the  patient  may  be  able  to  speak ;  but  he 
skips  words,  uses  wrong  ones,  and  consequently  talks  con- 
fusedly.    This  is  called  paraphasia  or  conduction  aphasia. 

Each  of  these  forms  of  aphasia  is  further  divided  into 
cortical  and  subcortical,  according  as  the  lesion  is  in  the  cen- 
tre itself  or  in  one  of  the  tracts  leading  either  to  or  from  it. 
The  symptoms  due  to  a  cortical  lesion  differ  somewhat  from 
those  due  to  a  subcortical  one.  Thus  we  have  cortical  and 
subcortical  motor  aphasia,  and  similarly  with  the  other  forms. 

Aphasia — the  genesis  of  speech  :  Location  of  centres :  For 
the  proper  understanding  of  aphasia  some  knowledge  of  the 
method  of  development  of  language  is  essential.  The  child 
learns  to  understand  language  before  he  can  utter  it.  By 
the  employment  of  the  different  senses,  he  perceives  the  dif- 
ferent characteristics  and  appearance  of  an  object.  This 
percept  is  stored  away  in  the  brain,  and  gradually  the  child 
learns  to  associate  the  name  of  the  object  which  he  hears 
applied  to  it  with  that  object.  The  memory  of  the  sound  of 
this  word  is  stored  in  a  certain  part  of  the  brain  (left  first  tem- 
poral convolution),  so  that  hereafter  when  the  word  designat- 
ing the  object  is  used  its  various  characteristics  are  at  once 
brought  into  consciousness  by  a  stimulation  of  the  different 
centers  where  the  memories  of  these  characteristics  are  stored. 
Finally  the  child,  probably  by  watching  the  muscular  move- 
ments employed  by  others  in  pronouncing  the  word,  learns 
to  make  them  himself.  These  memories  of  the  proper  mus- 
cular movements  necessary  to  pronounce  a  word  are  also 
stored  away  in  a  certain  part  of  the  brain. 

The  exciting  of  one  of  these  centres  excites  the  others  ;  for 
instance,  if  we  hear  the  sound  of  a  bell,  a  mental  image  of 
the  other  characteristics  of  a  bell  is  at  once  formed,  and  the 
proper  word  designating  that  image  comes  into  consciousness. 
Then  if  it  is  wished  to  articulate  the  word,  the  properly  co- 
ordinated muscular  movements  are  made  and  the  word  is 
pronoimced. 


244  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

But  even  if  the  word  is  not  pronounced,  as  in  silent  think- 
ing, mental  images  of  words  enter  into  thought-processes. 
Any  one  can  mentally  recall  the  sound  of  a  word,  as  he  can 
also  the  visual  appearance  of  it  when  written.  This  is  being 
constantly  done  while  thinking. 

This  revival  of  ivords,  which  in  most  cases  is  first  in  the 
auditory  centre  (first  temporal  convolution),  is  immediately 
followed  by  a  revival  of  the  kinresthetic  memory,  or  the  mem- 
ory of  sensory  impressions  resulting  from  the  movements  of 
the  vocal  organs  during  the  utterance  of  words  (glosso- 
kinsesthetic  centre  or,  as  it  is  sometimes  called,  psycho-motor 
centre,  in  the  left  third  frontal  convolution).  This  is  termed 
the  internal  language. 

We  learn  to  read  by  associating  the  visual  appearance  of 
certain  symbols  with  certain  sounds  already  familiar  with 
the  visual  memories  of  these  symbols.  The  so-called  visual 
memories  are  stored  in  the  cortex  (angular  gyrus).  In  reading 
aloud,  the  words  which  are  primarily  perceived  in  the  visual 
center  at  once  call  up  the  corresponding  sound  in  the  auditory 
centre ;  from  which  the  glosso-kinsesthetic  centre  is  stimu- 
lated and  the  memories  of  the  required  muscular  movements 
are  called  up  to  articulate  the  word.  These  impressions  are 
now  sent  to  the  centres  for  these  muscles  at  the  foot  of  the 
central  convolutions. 

When  we  read  silently  the  internal  language  is  employed 
in  the  same  way. 

In  writing,  which  is  usually  next  learned,  the  child  learns 
to  associate  the  visual  perceptions  of  the  letters  with  certain 
muscular  movements  of  the  fingers  and  arm  required  to 
make  them.  The  memories  of  these  movements  are,  as  in 
the  case  of  speech,  stored  up  in  a  centre — the  cheiro-kinaes- 
thetic  centre — thought  to  be  situated  in  the  second  frontal 
conv^olution  on  the  left  side.  As  in  writing  each  letter  is 
self-dictated  by  means  of  either  spoken  or  internal  language, 
the  other  centres  involved  in  these  processes  are  first  excited. 
Reference  to  tlie  diagram  will  show  the  location  of  the  cen- 
tres mentioned  and  their  probable  connections. 

Cortical  auditory  aphasia:  In  this  form  the  lesion  is  at  A. 
There  would  be  loss  of  the  power  of  understanding  spoken 


CORTICAL  AUniTOltY  APHASIA. 


245 


words;  nor  could  words  he  rcpcatcdor  written  from  dictatioji. 
As  stimulation  of  tliis  centre  is  necessary  to  hrinj^  UK  into 
activity,  spoken  speech  would  be  defective,  wrong-  words 
would  be  used,  and  paraphasia  would  result.      For  the  same 


Fig.  48. 


Diagram  showing  probable  pathways  of  nervous  impulses  concerned  in  speech  and 
writing,  i  A.  centre  for  auditory  word-memories  in  first  temporal  convolution  ; 
V,  center  for  visual  word-memories  in  angular  gyrus  ;  GK,  glosso-kinsesthotic 
centre  (Bastian),  or  psycho-motor  centre,  at  foot  of  third  temporal  convolution ; 
TJ,  centres  for  muscles  involved  in  articulation  at  foot  of  central  convolutions  ; 
CK,  probable  centres  for  memory  of  muscular  movements  involved  in  writing, 
cheiro-kinsesthetic  centre  of  Bastian  ;  IF,  centres  for  controlling  muscles  of  arm 
and  hand  in  central  convolutions:  A'-A,  tract  from  cortex  of  temporal  lobe 
(auditory  centres)  to  centre  for  word-memories:  F'-T',  tract  from  cuneus  to 
centre  for  visual  memories;  H-Tl'',  tract  from  arm  and  hand  centres  to  cells 
in  anterior  horns  of  cord  and  peripheral  nerves  controlling  these  muscles 
(pyramidal  tract);  [/■-[/■',  tract  from  centres  for  muscles  of  articulation  to  cen- 
tres in  pons  and  medulla  and  nerves  controlling  those  muscles  (pyramidal 
tract).  In  speaking,  impulses  travel  from  A-GK-U-U' ;  in  reading  aloud, 
from  V-A-GK-U-U';  in  silent  reading,  from  V-A-GK;  in  writing  spontaneously, 
V-A-SK-CK-W-W';  in  writing  from  dictation,  A-V-GK-CK-]]-W ;  in  copying, 
V-CK-W-W. 


reason,  the  internal  language  being  interfered  with,  the 
power  of  reading  and  writing  would  also  be  interfered  with 
(tracts  V-A-GK  in  Fig.  48 j^ 

^  In  right-handefl  persons  tliese  centres  and  tracts  are  situated  in  the  left 
side  of  the  brain ;  in  left-lianded  persons  the  opposite  is  the  case. 


246   DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

Subcortical  auditory  aphasia :  In  this  form  the  lesion  is  in 
the  tract  A'-A.  The  centre  A  is  intact.  The  patient  is  un- 
able to  understand  spoken  words,  or  to  repeat  or  write  from 
dictation.  There  may  also  be  some  paraphasia,  as  the  patient 
has  not  the  benefit  of  hearing  the  word  to  know  its  correct- 
ness. The  internal  language  being  intact,  word-memories 
can  be  recalled  (in  centre  J.),  and  reading  and  writing  are  not 
interfered  with  (tract  V—A-GK,  Fig.  48). 

Cortical  visual  aphasia :  The  lesion  is  in  the  center  Y ;  the 
patient  is  unable  to  read  (alexia)  aloud  or  silently ;  to  write 
spontaneously,  from  dictation,  or  to  copy.  Volitional  speech 
is  not  interfered  with. 

Subcortical  visual  aphasia:  Lesion  in  tract  V^—Y.  Ability 
to  read  and  to  copy  understandingly  is  lost.  By  means  of 
tract  T-CiThecan  copy  mechanically.  As  the  centre  Fis 
intact,  visual  memories  can  be  recalled  ;  hence  the  patient 
can  write,  but  not  with  facility,  he  being  in  the  position  of 
one  writing  with  his  eyes  closed. 

Cortical  motor  aphasia  :  The  lesion  is  in  the  centre  G-K. 
Volitional  speech  and  repeating  words  and  reading  out  loud 
are  lost.  Owing  to  the  interference  with  the  internal  lan- 
guage, silent  reading  and  writing  are  also  \ost{Y-A—GK, 
Fig.  48).     Language  is  understood. 

Subcortical  motor  aphasia :  This  is  the  purest  form  of  motor 
aphasia.  Lesion  in  the  tract  GK-  U.  Volitional  speech,  re- 
peating words,  and  reading  aloud  are  lost.  The  internnl 
language  being  intact,  as  the  centre  G-K  is  intact,  silent  read- 
ing and  writing  are  not  interfered  with.  Language  can  be 
understood. 

Motor  and  sensory  aphasia :  Rarely  it  happens  that  two  or 
more  of  these  centres  are  diseased,  in  which  case  there  would 
be  a  combination  of  the  symptoms  above  described. 

Aphasia — diagnosis :  In  examining  a  case  of  aphasia  the 
following  questions  proposed  by  Dana  will  be  found 
useful : 

1.  Can  he  hear  sounds? 

2.  Can  he  hear  spoken  words  ? 

3.  Can  he  understand  the  words  spoken? 

4.  Can  he  see  objects? 


THE  BLOOD-SUPPLY  OF  THE  BRAIN.  247 

5.  Can  he  see  words  written  or  printed  Miid  read  them 
silently  ? 

6.  Can  he  understand  written  words — i.  e.,  can  lie  read  in- 
telligently ? 

7.  Can  he  speak  voluntarily? 

8.  Can  he  repeat  words? 

9.  Can  he  read  aloud  ? 

10.  Can  he  write  voluntarily? 

11.  Can  he  write  to  dictation? 

12.  Can  he  copy? 

By  an  analysis  of  the  answers  to  these  questions  a  diagnosis 
can  readily  be  made. 

In  motor  aphasia  the  possibility  of  paralysis  of  the  muscles 
employed  in  articulating  must  be  eliminated.  Hemianopsia 
usually  accompanies  visual  aphasia. 

Etiology :  While  most  cases  of  aphasia  are  due  to  a  de- 
structive lesion — either  tumor,  acute  hemorrhagic  encephalitis, 
abscess,  hemorrhage,  or  acute  softening  of  the  centres  and 
tracts — it  must  be  borne  in  mind  that  less  commonly  aphasia, 
usually  transient,  maybe  produced  hy  fancti  on  al  disturbances 
— i.  €.,  epilepsy,  migraine,  neurasthenia,  hysteria,  toxaemias 
of  various  sorts,  as  uraemia,  diabetes,  gout,  alcohol,  and  min- 
eral and  vegetable  poisons ;  fright,  anger,  and  loss  of  blood. 
Some  of  these  cases,  especially  the  ursemic,  may  be  due  to 
diseased  bloodvessels  produced  by  the  action  of  the  poison. 

The  prognosis  is  better  in  children  than  in  adults,  as  in  them 
education  of  the  centres  upon  the  other  side  of  the  brain 
takes  place,  and  consequently  restoration  of  the  lost  function. 
In  adults  more  or  less  improvement  often  takes  place.  The 
outlook  in  sensory  aphasia  is  better  than  in  motor. 

The  treatment  is  in  the  first  place  that  of  the  lesion  causing 
it ;  in  the  second  place,  of  the  symptoms.  This  consists  of 
reeducation  by  the  usual  methods  employed  in  teaching  chil- 
dren to  speak,  read,  and  write. 

AFFECTIONS  OF  THE  BLOODVESSELS. 
The  Blood-supply  of  the  Brain. 

The  external  carotids  furnish  the  blood  to  the  scalp,  skull, 
and  dura  mater. 


248   DIFFUSE  AND  LOCAL  DISEASES   OF  THE  DRAIN. 

To  the  neurologist  tlie  middle  meningeal,  wliich  ai'ises  from 
the  internal  maxillary,  is  the  most  important  branch.  It 
supplies  that  part  of  the  dura  situated  c»ver  the  sensori-motor 
region,  and  is  frequently  the  souree  of  hemorrhage  due  to 
traumatism. 

The  internal  carotids  and  vertebrals  furnish  the  blood  to 
the  pia  mater  and  brain-substance. 

Each  internal  carotid  divides  into  two  branches — the  ante- 

FiG.  49. 


Diagram  of  the  arteries  of  the  base  of  the  brain,  showing  LO,  the  lenticular  optic, 
and  LS,  lentieular  striate  sets  of  arteries.  One  of  the  latter  is  called  the  artery 
of  cerebral  hemorrhage.  T',  A.  vertebralis  ;  8.a.,  spinalis  ant.;  .S.p.,  spinalis  pos- 
terior ;  B,  A.  basilaris  with  median  branches  :  C.b.s.,  A.  cerebralis  superior  ;  c.i., 
A.  cerebelli  inferior:  C.p.,  A.  cerebralis  posterior  (profunda  cerebri) ;  Com.  p.,  A. 
communicantes  posteriores;  C'.a.i.,  carotis  interna;  o,  A.  ophthalmica ;  Cm.,  A. 
cerebralis  media  (A.  fossae  Sylvii) ;  i.,  A.  insularis ;  est.,  A.  corp.  striati ;  C.a.,  A. 
cerebralis  anterior:  Com.,  A.  communicans  anterior;  C  c.a.Z?.,  A.  corp.  callosi. 
Shaded  vesnels— most  common  seat  of  liemorrhage. 


rior  and  middle  cerebrals.     The   two   former  are   united  by 
the  anterior  communicating. 

The  vertebrals  unite  to  form  the  basilar,  which  divides  into 
the  two  posterior  cerebrals  ;  these  are  united  with  the  internal 


THE  BLOOD-SUPPLY  OF  THE  BRAIN. 


240 


carotids  by  tlie  posterior  coinmiinioatiiig  arteries.     Tliis  ar- 
rangement is  known  as  the  circle  of  Willis  (Fig.  4!)). 

Central  arteries  :  From  the  circle  of  Willis  and  the  l)egin- 
nings  of  the  anterior,  middle,  and  posterior  cerebral  arteries 
are  given  off'  six  gronps  of  vessels,  kno-svn  as  the  central 
arteries.  These  supply  the  basal  ganglia  and  adjacent  wliite 
matter.  These  are  all  end-arteries,  conseqiientlv  do  not 
anastomose,  and  are  the  vessels  usually  affected  in  cerebral 
hemorrhage  in  adults.     The  most  important  are  those  given 


Fig.  50. 


Transverse  section  of  the  cerebral  hemispheres,  about  1  cm.  behind  the  optic  com- 
missure. Ch,  chiasma  ;  B,  section  of  the  optic  tract ;  L,  lenticular  nucleus  •  I 
internal  capsule;  C,  caudate  nucleus;  E,  external  capsule;  T,  claustrum  •' J?' 
island  of  Reil ;  T',  T',  section  of  the  lateral  ventricle  ;  P,  P,  anterior  pillars  of 
the  fornix  ;  0,  gray  substance  of  the  third  ventricle.  Vasadar  arra.-!  ■  I  anterior 
cerebral  artery  ;  II,  middle  cerebral  artery  :  III,  posterior  cerebral  artery  1  in- 
ternal carotid  artery  ;  2,  Sylvian  artery  ;  3,  anterior  cerebral  arterv  ■  4  4  external 
arteries  ol  tlie  corpus  striatum  (lenliculo-striate  artery);  »,  5,  internal  arteries 
ot  the  striatum  (lenticular  arteries);  6,  arteries  of  ihe  chiasma;  7  arteries  of 
the  commissure  and  anterior  pillars  of  the  fornix  ;  S,  arteries  of  the  convolu- 
tions of  the  insula  and  claustrum.  The  opto-striate  artery  is  not  represented  in 
the  figure  (Duret).  ^ 


off  from  the  middle  cerebral,  consisting  of  two  groups,  the 
lenticular  and  lenticulo-striate.  These  supply  the  corpora 
striata,  part  of  the  optic  thalami,  and  internal  and  external 
capsules.  One  of  them  is  tlie  most  common  seat  of  hemor- 
rhage (Fig.  49).     Branches  of  the  posterior  cerebral  supply 


250   DIFFUSE  AND  LOCAL   DLSFASPJS   OF  THE  BRAIN. 

most  of  the  optic  thalamus,  the  corpora  quaxlrigeiuina,  the  inner 
part  of  the  crns  cerebri,  and  the  walls  of  the  third  ventricle. 
Cortical  arteries  :  The  anterior,  middle,  and  posterior  cere- 
brals  themselves    are   distributed    over    the    cortex    in    the 

Fig.   51. 

3     12 


V 


/-. 


V    / 


Branches  of  middle  cerebral,  anterior  cerebral,  and  posterior  cerebral  (Buret). 
1,  carotid  artery;  2,  Sylvian,  or  middle  cerebral,  artery:  3,  anterior  cerebral 
artery  ;  4,  posterior  cerebral  artery  ;  .'>,  arteries  of  the  corpus  striatum  ;  6.  ante- 
rior choroideal  a,rtery;  7,  posterior  communicating  artery;  8,  posterolateral 
choroideal  artery;  9,  postero-median  choroideal  artery;  10,  termination  of  eal- 
losal  arteries;   11,  middle  quadrigeminal  arteries;   12,  postero-internal   optic 


artery. 


pia  mater ;  from  there  branches  penetrate  into  the  cortex 
and  adjacent  white  matter.  These  are  known  as  cortical 
arteries.  Each  of  the  cerebrals  has  a  somewhat  distinct  area 
of  the  cortex  which  it  supplies.     The  anterior  cerebral  sup- 


SPONTANEOUS  MKNINGKAJ.   JIEMORRlIAdK.         251 

plies  thfi  greater  part  of  tlie  frontal  lobes ;  the  middle  cere- 
brals, the  central  convolutions  (sensori-motor  region)  and 
island  ol'  Reil  and  some  of  the  temporal  and  parietal  lobes  ; 
the  posterior  cerebral  supplies  the  occipital  and  part  of  the 
temporal  lobes.  There  is  some  anastomosis  between  the 
branches  of  these  vessels  ;  so  that  if,  for  instance,  a  branch 
of  the  anterior  cerebral  were  plugged,  some  vicarious  circu- 
lation would  occur  from  the  middle  cerebral. 

The  pons  and  cerebellum  are  principally  supplied  by 
branches  from  the  basilar,  the  medulla,  and  part  of  the  cere- 
bellum by  branches  given  off"  from  the  vertebrals  before  they 
unite  to  form  the  basilar. 

The  veins :  The  blood  from  the  convexity  and  median  sur- 
face of  the  cerebral  hemispheres  is  collected  by  veins  which 
empty  into  the  longitudinal  sinus.  That  from  the  inferior 
and  lower  surfaces  reaches  the  cavernous,  superior  petrosal, 
and  lateral  sinuses.  The  venous  blood  from  the  distribution 
of  the  central  arteries  enters  the  veins  of  Galen  and  from 
thence  the  straight  sinus.  The  blood  from  the  cerebellum 
partly  reaches  the  straight  and  partly  the  superior  petrosal 
and  lateral  sinuses,  while  that  from  the  under  surface  of  the 
cerebellum  and  the  pons  and  medulla  enters  the  inferior 
petrosal,  lateral,  and  occipital  sinuses. 

Meningeal  Hemorrhage. 

Hemorrhages  into  the  meninges  of  the  brain  may  occur  in 
various  situations — viz.,  into  the  meshes  of  the  pia  mater, 
which  would,  of  conrse,  include  the  brain  cortex  ;  into  the 
subdural  space ;  and  between  the  external  layer  of  the  dura 
and  the  cranium.  It  may  be  spontaneous,  but  is  nsually 
traumatic. 

Spontaneous  Meningeal  Hemorrhage. 

Etiology :  Spontaneous  hemorrhage  wIkmi  it  occurs  in 
adults,  which  it  rarely  does,  is  due  to  the  same  causes  that 
produce  intracerebral  hemorrhage  (see  p.  254).  That  occurring 
in  children  is  more  common,  and  has  been  discussed  on  p.  200. 

The  symptoms  de])end  on  the  situation  and  size  of  the 
hemorrhage.  If  subdural,  they  may  consist  of  sudden  severe 
headache,  vomiting,  and    signs  of  meningeal  irritation  (see 


252  DIFFUSE  AND   LOCAL   DISEASES  OF  THE  BRAIN. 

Meningitis).  These  symptoms  occnrring  in  a  plethoric  person 
after  eating  or  nuiscular  exertion  are  suspicious. 

If  pial,  the  symptoms  are  headache,  convulsions,  possibly 
of  Jacksonian  type,  followed  by  coma,  and  paralysis  situated 
according  to  the  location  of  the  hemorrhage. 

The  treatment  is  similar  to  that  employed  for  cerebral 
hemorrhage  (see  p.  261). 

Traumatic  Meningeal  Hemorrhage. 

Etiology :  This  is  due  to  the  rupture  of  a  vessel,  most  fre- 
quently a  branch  of  the  middle  meningeal  artery,  caused  by 
a  blow  upon  the  head,  which  in  most  cases  also  causes  fract- 
ure of  the  skull. 

Symptoms :  When  the  hemorrhage  is  from  the  middle 
meningeal  the  clot  is  extradural,  and  the  usual  history  is  that 
for  a  varying  length  of  time — a  few  minutes  to  several  hours ^ 
— after  receiving  the  blow  the  patient  presents  very  few  or 
no  symptojns.  Then  he  gradully  becomes  stupid,  and  finally 
comatose.  Motor  disturbances  then  make  their  appearance. 
More  or  less  marked  hemiplegia,  which  may  or  may  not  be 
preceded  by  twitchings  of  the  leg  or  arm,  or  both,  is  the  most 
common  ;  or  there  may  be  muscular  twitchings  and  rigidity 
of  both  legs  or  of  legs  and  arms.  Paraplegia  has  been  pres- 
ent in  a  few  cases.  The  paralysis  may  be  very  slight  and 
soon  disappear,  or  there  may  be  no  motor  symptoms  discover- 
able. The  pupil  upon  the  injured  side  is  frequently  dilated 
(Hutchinson's  pupil),  and  when  present  indicates  that  the 
hemorrhage  has  reached  the  base  and  is  pressing  upon  the 
third  nerve.  The  pulse  at  first  is  slow,  becoming  rapid  later. 
The  respiration  is  slow,  labored,  possibly  stertorous,  and  the 
temperature  may  be  elevated. 

In  severe  cases  concussion  symptoms  complicate  the  case, 
and  there  may  be  no  interval  of  retained  consciousness. 

When  the  hemorrhage  is  subdural,  it  may  occur  from  a 
vein  or  sinus,  and  the  symptoms  (coma  and  paralysis)  develop 
quicker,  often  at  once,  and  are  apt  to  be  more  marked.  There 
is  also  more  shock,  the  temperature  after  the  injury  going 
frequently  to  95°  to  96°  F. 

^  Cases  liave  been  reported  in  which  days  elapsed  before  symptoms  ap- 
oeared. 


TRAUMATIC  MENINGEAL  HEMORRHAGE. 


or.n 


Traumatic  meningeal  hemorrhage — diagnosis:  The  diagnosis 
is  based  upon  the  .syni])toms  above  detailed,  following  a  blow 
upon  the  head.  While  evidenee  of  the  trauma  is  usually 
visible  upon  the  seal}),  it  luay  be  absent. 

Walton  ^  has  recently  called  attention  to  the  fact  that  a 
severe  concussion,  attended  by  contusion  and  laceration  of 
the  brain-cortex  and  subarachnoid  serous  exudation  at  the 
seat  of  injury,  may,  if  the  injury  is  in  the  motor  region,  pro- 
duce symptoms  simulating  meningeal  hemorrhage.  As  aids 
in  distinguishing  this  condition  from  hemorrhage,  he  gives 
the  following  :  (a)  an  atypical  course  ;  {b)  absence  of  steadily 

¥iQ.  52. 


Points  at  which  to  trephine  in  hemorrhage  from  the  middle  meningeal  arterv  (after 
Kronlein,  Esmarch,  and  Kowalsky).  ab,  horizontal  line  drawn  through  the 
meatus;  cd,  through  the  eyebrow;  ej',  vertical  line,  %cm.  behind  the  external 
angular  process ;  gh,  immediately  behind  the  mastoid  process.  The  intersec- 
tions A  and  B  mark  the  points  for  trephining  to  find  respectively  the  anterior 
and  posterior  branches  of  the  artery. 

increasing  coma  ;  (c)  appearance  of  sensitiveness  to  pain  on 
manipulation  of  the  head,  even  after  the  unconsciousness  is  so 
great  that  questions  are  not  answered  ;  and  {(J)  the  occurrence 
of  the  symptoms  in  children  and  young  adults  and  in  alco- 
holics. Such  cases  often  recover  without  operation. 
'  Amer.  .lour.  Med.  Sci.,  \).  2G7,  Sept.,  1S98. 


254   DIFFUSE  AND   LOCAL  DISEASES  OF  THE  BRAIN. 

It  ^>houkl  alrio  be  remembered  that  sometimes  the  hemor- 
rhage may  take  place  from  the  side  opposite  the  one  that 
received  the  blow. 

The  prognosis  depends  upon  the  seat  of  the  hemorrhage ; 
supra-  or  suljdural ;  and  whether  its  seat  can  be  reached  by 
surgical  means. 

In  supradural  hcmoi-rhage,  if  recognized  early,  the  prognosis 
is  hopeful.  Subdural  hemorrhages  are  harder  to  recognize, 
and  when  they  are  the  prognosis  is  not  so  good.  The  pos- 
sibility of  extensive  laceration  of  and  hemorrhage  into  the 
brain -substance  coexisting  must  be  borne  in  mind. 

The  treatment  is  surgical,  and  consists  of  trephining  over 
the  probable  seat  of  hemorrhage,  removing  the  clot,  and  secur- 
ing the  vessel.  In  deciding  the  location  we  are  guided  by 
the  symptoms  :  if  motor  symptoms  are  present,  the  trephine 
is  first  applied  upon  the  opposite  side.  If  no  clot  is  there 
found,  the  operation  should  be  repeated  upon  the  other  side. 

If  no  localizing  symptoms  are  present,  trephine  over  the 
seat  of  injury.  For  the  method  of  locating  the  artery,  see 
Fig.  52. 

Cerebral  Hemorrhage. 

Etiology:  The  symptoms  produced  by  either  cerebral  hem- 
orrhage, embolism,  or  thrombosis  are  familiarly  termed 
apop/e.vjf.  At  the  time  of  birth  and  during  infancy  there  is 
some  tendency  to  cerebral  hemorrhage  (see  Cerebral  Palsies 
of  Children).  From  this  period  until  the  age  of  forty  the 
liability  is  small ;  after  this  the  liability  progressively  in- 
creases. More  cases  occur  in  cold  weather  and  at  high  alti- 
tudes. Hereditary  influence,  insomuch  as  it  predisposes  to 
renal  and  arterial  disease,  is  a  factor.  The  most  important 
predisposing  cause  is  chronic  alcoholism  ;  next  syphilis,  then 
gout.  Because  they  produce  fatty  changes  in  the  vessel- 
walls,  hemorrhage  sometimes  follows  the  infectious  fevers. 
It  may  also,  rarely,  complicate  purpura  hsemorrhagica  and 
scurvy.  Violent  exertion,  as  the  lifting  of  heavy  weights  ; 
straining  at  stool,  the  act  of  coitus,  and  mental  excitement, 
may  act  as  exciting  causes.  Over-indulgence  in  alcohol  also 
may  act  in  this  way. 


CEREBRAL   HEMORRHAGE.  255 

Transient  apoplectifoini  attac^k.s  due  to  sudden  congestion 
occur  in  brain-tumor  and  paretic  dementia. 

Cerebral  hemorrhage — symptoms :  The  symjitoms  are  divided 
into  those  of  the  attack  and  acute  stage  foUowing  ;  and,  if 
the  patient  survive,  the  succeeding  chronic  state.  The  fol- 
lowing description  applies  to  the  usual  form  of  attack — that 
due  to  hemorrhage  from  one  of  the  lenticulo-striate  arteries  : 

Prodromal  symptoms  are  rare,  excepting  in  cases  due  to 
syphilis  :  patients  may  complain  for  a  few  days  previous  of 
vertigo,  numbness  of  the  hand  or  foot,  mental  confusion,  loss 
of  memory,  and  headache. 

The  attack  is  always  sudden,  and  may  be  accompanied  by 
convulsions  and  coma  ;  coma  alone ;  or  consciousness  may  be 
preserved. 

Convulsions  are  rare  in  cerebral  hemorrhage,  and  when 
present  usually  indicate  hemorrhage  from  a  cortical  artery 
(middle  cerebral),  as  the  cortical  cells  would  be  then 
irritated. 

The  usual  mode  of  onset  is  for  the  patient,  Avithout  warn- 
ing, to  become  suddenly  dizzy,  lose  consciousness,  and  fall. 
The  face  will  be  flushed ;  the  pulse  slow,  full,  and  tense ;  the 
breathing  stertorous ;  the  eyeballs  fixed  or  deviated  to  the 
paralyzed  size  (conjugate  deviation) ;  the  pupils  contracted 
and  irresponsive  to  light ;  the  skin  bathed  in  sweat  and  the 
limbs  relaxed,  those  of  the  side  which  is  paralyzed  being 
more  so  than  those  of  the  other ;  the  mouth  will  also  proba- 
bly be  drawn  toward  the  unparalyzed  side.  The  urine  may 
be  retained ;  or,  with  the  fseces,  evacuated  involuntarily.  If 
the  hemorrhage  is  severe,  the  temperature  may  be  subnormal 
during  the  first  few  hours.  After  this,  as  a  rule,  the  temper- 
ature rises,  that  of  the  paralyzed  side  being  frequently  1° 
to  2°  F.  higher  than  the  other.  This  condition  is  maintained 
throughout  the  acute  stage. 

In  some  cases  the  coma  continues  :  the  respiration  assinnes 
the  Oheyne-Stokes  tyjie ;  the  temperature  rises  ;  swallowing 
is  impossible,  and  deatli  occurs  in  a  few  days.  In  other  cases 
the  patient  niay  partially  regain  consciousness,  but  is  stu- 
porous, with  perhaps  mild  delirium.  He  is  restless  and  com- 
jilains  of  headache.  This  may  continue  for  two  or  three 
weeks,  when  the  temperatui'e    rises  above  normal,  bedsores 


256   DIFFUSE  AND   LOCAL  DISEASES   OF  THE  BRAIN. 

develop,  pneiiiiionia  sets  in,  consciousness  is  again  lost,  and 
death  ensues. 

In  the  favorable  cases  the  coma  passes  away  in  a  few  hours, 
although  the  patient  may  be  mentally  confused ;  on  one  side 
will  be  found  paralysis  of  the  arm,  leg,  and  lower  part  of  the 
face,  the  tongue  when  protruded  pointing  toward  the  para- 
lyzed side.  The  speech  is  thick  and  indistinct ;  in  hemor- 
rhage upon  the  left  side  there  may  be  aphasia.  Slight  anaes- 
thesia may  also  be  found. 

At  first  the  paralysis  is  flaccid  and  the  deep  reflexes  lessened 
or  absent,  or  more  rarely  the  muscles  are  rigid  from  the 
start  (early  rigidity  due  to  irritation).  For  the  first  few  days 
the  temperature  is  above  normal,  being  higher  in  the  para- 
lyzed side,  and  then  falls  to  normal.  If  the  temperature 
continues  to  rise  after  the  fourth  or  fifth  day,  it  is  a  sign  of 
extension  of  the  hemorrhage  or  severe  inflammatory  reaction. 

The  chronic  stage :  At  the  end  of  three  or  four  weeks,  if 
symptoms  of  cerebral  irritation  have  disappeared,  the  chronic 
stage  begins.  By  this  time  the  paralysis  of  the  face  and 
tongue  has  either  improved  or  disappeared,  and  some  power 
of  movement  of  the  arm  and  leg  has  returned.  The  improve- 
ment is  usually  noticed  first  in  the  leg,  which  recovers  more 
rapidly  and  to  a  greater  extent  than  does  the  arm.  The  mus- 
cles near  the  trunk  also  regain  more  power  than  do  the  distal 
ones.  Sensory  symptoms  have  disappeared.  The  muscles 
that  act  bilaterally  are  most  slightly  involved.  About  the  end 
of  the  second  week  rigidity  of  the  muscles  develops  (this  is 
termed  late  rigidity),  which  usually  increases  until  contract- 
ures affect  the  paralyzed  limbs,  producing  deformities  of 
greater  or  less  degree.  The  deep  reflexes  become  exaggerated. 
In  walking,  the  toe  is  dragged  and  the  leg  swung  from  the 
liip  in  the  arc  of  a  circle.  The  muscles  do  not  waste.^  In 
the  hemiplegia  of  adults,  the  disorders  of  movement,  atheto- 
sis, etc.,  which  frequently  occur  in  children  and  are  described 
on  p.  35,  but  rarely  occur. 

Unless  the  posterior  part  of  the  capsule  is  involved,  hemi- 
ansesthesia  is  not  present.     In   some  cases  pain  in  the  arm 

^  Tliis  is  the  fact  in  nearly  all  cases.  A  few,  however,  linve  lieen  reported 
in  which  there  was  atropliy,  without  deuionstrable  lesion  of  the  peripheral 
neuron. 


CEREBRAL  HEMORRHAGE.  257 

and  leg  is  complained  of.  Vaso-motor  disturbances  as 
cyanosis,  sweating,  etc.,  may  be  present.  The  mental  condi- 
tion is  usually  more  or  less  affected,  the  patient  being  emo- 
tional and  irritable ;  the  memory  fails,  and  in  some  cases 
complete  dementia  develops. 

Ingravescent  apoplexy  is  a  special  form  in  which  the  patient 
is  seized  with  sudden  vertigo,  headache,  and  vomiting,  but 
without  loss  of  consciousness.  Hemiplegia,  with  hemianses- 
thesia,  sets  in  and  in  about  twenty-four  hours  the  patient 
becomes  stupid  and  finally  comatose,  with  death  in  from  three 
to  five  days.  The  vessel  ruptured  is  one  of  the  lenticular 
branches,  the  hemorrhage  being  mainly  at  first  in  the  external 
capsule,  breaking  through  the  white  matter,  and  finally  reach- 
ing the  lateral  ventricle. 

Hemorrhage  into  the  pons :  This  is  accompanied  with  loss 
of  consciousness,  frequently  with  spasmodic  movements  of 
the  limbs,  marked  contraction  of  the  pupils,  slow  respira- 
tion, high  temperature — 103°  to  104°  F.  The  facial  and 
ocular  muscles  and  those  of  articulation  and  swallowing  may 
be  involved,  and  there  is  more  or  less  marked  paralysis  of 
motion  and  sensation,  usually  unilateral.  Crossed  paralyses 
frequently  occur  (see  Fig.  47). 

Hemorrhage  into  the  cerebellum :  These  are  difficult  to 
recognize.  There  may  be  a  preliminary  period  of  headache ; 
or  the  patient  may  fall  into  a  state  of  coma,  as  in  hemor- 
rhage elsewhere.  Vomiting  may  occur.  If  hemiplegia 
occurs,  it  is  on  the  side  of  the  lesion  (decussation  has  oc- 
curred). Respiration  and  swallowing  are  usually  much 
affected,  as  the  fourth  ventricle  is  almost  sure  to  be  involved. 
Death  usually  occurs. 

Cerebral  hemorrhage — morbid  anatomy  and  pathology :  The 
hemorrhage;  (though  possibly  traumatic  in  rare  cases)  is 
almost  always  due  to  disease  of  the  l^loodvessels.  This  may 
consist  of: 

First :  A  (hyeneratwc,  arieritu,  \\'hich  results  in  the  forma- 
tion of  miliary  aneurisms,  the  ni])ture  of  wliieli  causes  the 
hemorrliage.  "^i'he  degeueration  first  attacks  the  media.  The 
17— \.  1». 


258   DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BBAIN. 

UOWER_J;IMB 


Fig  ri3— Showing  the  secondary  degeneration  which  occurs  with  cerebral  hemor- 
rhage or  softening,  and  which  follows  the  course  of  the  motor  tracts  into  the 
hpinal  cord.  H,  site  of  lesion.  The  cnntinnons  lines  are  fibres  gmng  to  the  lees, 
the  dotted  are  those  going  to  arms  and  motor  cranial  nerves  (modified  trora  Van 
Gehuchten). 


CEREBRAL  HEMORRHAGE.  259 

aneurisms  occur  most  frequently  upon  the  cortical  vessels, 
but  may  also  be  on  the  smaller  cortical  ones.  On  section  of 
the  brain-substance  they  appear  as  localized,  dark  bodies  about 
the  size  of  a  pin's  head. 

Second  :  Endarteritu  and  peri-arteritis  may  lead  to  apoplexy 
either  by  producing  miliary  aneurisms  or  coarse  ones  of  the 
larger  vessels  of  the  circle  of  Willis. 

Third  :  Fatty  degeneration  of  the  small  vessels  occurring 
in  purpura,  scurvy,  leukocythsemia,  marasmic  conditions,  and 
acute  infectious  diseases.  Atheroma  is  usually  found  in  the 
larger  vessels. 

The  parts  infected  in  hemorrhage,  in  the  order  of  frequency, 
are  :  the  caudate  and  lenticular  nuclei,  meninges  and  cortex, 
centrum  ovale,  optic  thalamus,  pons,  cerebellum,  and  medulla. 
Ventricular  hemorrhages  are  usually  secondary  to  hemor- 
rhage into  the  neighborhood  of  the  basal  ganglia. 

After  a  hemorrhage  there  is  first  coagulation  of  the  blood, 
which  soon  begins  to  soften  and  be  absorbed.  The  inflamma- 
tion occurring  about  the  clot  usually  causes  the  formation  of 
a  fibrinous  wall  about  it,  which  forms  a  cyst  with  fluid  con- 
tents. In  other  cases,  instead  of  the  formation  of  a  cyst, 
there  is  proliferation  of  connective  tissue  and  the  formation 
of  a  pigmented  scar. 

Secondary  degenerations  follow,  due  to  the  cutting  off  of 
nerve-fibres  from  their  parent-cells,  which  in  most  cases,  as 
hemorrhage  in  the  region  of  the  internal  capsule  is  most 
common,  would  involve  the  pyramidal  tract  and  be  the  cause 
of  late  rigidity  and  increased  reflexes  (the  inhibitory  influ- 
ence of  the  cortical  cells  being  cut  ofP)  (see  Fig.  53). 

Cerebral  Hemorrhage — Diagnosis. 

Cerebral  hemorrhage,  when  its  onset  is  marked  by  coma, 
must  be  distinguished  from  coma  due  to  concussion  or  com- 
pression of  the  brain,  acute  alcoholism,  uraemia,  diabetes, 
opium-poisoning,  epilepsy,  and  hysteria ;  and  when  none 
of  these  is  found  to  cause  the  symptoms,  from  acute  soften- 
ing of  the  brain  due  to  blocking  of  a  cerebral  vessel  by  em- 
bolism or  thrombosis.  Both  concussion  and  compression  of 
the    brain    would  be  preceded    by  traumatism,  evidence  of 


260   DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

which  should  he  sought  for.     In  these  cases  the  possibility 
of  meningeal  hemorrhage  must  not  be  lost  sight  of. 

Alcoholic  coma  is  characterized  by  the  odor  of  alcohol  upon 
the  breath,  although  this  may  be  present,  of  course,  in  a  case 
of  hemorrhage  ;  incompleteness  of  the  coma ;  absence  of 
localized  paralysis,  unequal  and  contracted  pupils  (conjugate 
deviation),  and  low  or  unequal  temperature. 

Urssmic  coma  would  be  characterized  by  the  presence  of 
albumin  and  casts  in  the  urine,  although  albumin  may  be 
present  in  hemorrhage  when  there  is  no  renal  disease,  urinous 
odor  of  the  breath  ;  facies  common  to  chronic  nephritis — /.  c, 
pallor,  oedema,  etc.;  absence  of  unequal  pupils,  of  localized 
paralysis,  conjugate  deviation  of  the  eyes,  and  differences  of 
temperature  upon  the  two  sides.  In  addition  to  coma,  urse- 
mic  poisoning  may  produce  a  hemiplegia,  the  development  of 
which  may  or  may  not  be  preceded  by  convulsions  (see  also 
Brain-tumor) ;  or  hemiplegia  may  develop  without  previous 
coma.  Aphasia  may  also  be  so  caused.  These  cases,  while 
functional  in  origin,  due  to  the  action  of  tlie  ])oison  upon  the 
cells,  and  no  cerebral  lesions  being  found  after  death,  may 
closely  resemble  true  apoplexy.  They  are  usually  transient, 
and  such  attacks  associated  with  other  evidences  of  nephritis 
would  be  suggestive.  Of  course,  it  must  not  be  forgotten, 
that  diseased  kidneys  may  be  present  in  cases  of  true  apo- 
plexy. 

Diabetic  coma  is  distinguished  by  the  presence  of  sugar  in 
the  urine,  the  odor  of  acetone  on  the  breath,  and  the  absence 
of  paralysis. 

Cerebellar  hemorrhage  is  especially  liable  to  be  confounded 
with  diabetic  coma,  as  glycosuria  frequently  occurs  in  cere- 
bellar lesions.  Evidences  of  paralysis  would  be  in  favor  of 
hemorrhage.  A  history  of  the  other  symptoms  characteristic 
of  diabetes  could  be  ascertained  if  the  attack  was  one  of 
diabetic  coma. 

Opium-poisoning  is  accompanied  by  marked  and  equal  con- 
traction of  the  pupils,  extremely  slow  respiration,  and  ab- 
sence of  localized  paralysis   and  of  elevated  temperature. 

Pontine  hemorrhage  is  especially  apt  to  be  confounded  ;  the 
high  tem])cratiire  and  convulsions,  if  present,  occurring  in  it 
arc  valuable  diagnostic  jxjiuts.      In  coma  following  ej)ileptic 


CEREBRAL  HEMORRHAGE.  261 

convulsions  there  would  be  a  comparatively  nipid  return  of 
consciousness,  absence  of  paralysis,  and  the  history,  if  one 
can  be  obtained,  of  previous  attacks. 

Hysterical  coma  and  hemiplegia  will  be  described  under 
Hysteria,  pp.  350  and  358. 

In  cases  brought  to  a  hospital  without  previous  history,  the 
diagnosis  may  sometimes  be  most  difficult.  The  possibility 
of  any  of  the  above  causes  operating  must  be  borne  in  mind 
and  eliminated  if  possible.  Apoplectiform  seizures  occur  in 
general  paresis  and  brain-tumor,  but  are  usually  transient 
and  not  accompanied  by  paralysis.  A  syphilitic  meningitis 
may  also  simulate  apoplexy,  but  such  cases  are  usually  pre- 
ceded by  headache,  and  the  coma  in  most  instances  develops 
gradually ;  evidences  elsewhere  of  syphilitic  infection  should 
be  sought  for.  In  many  cases  the  diagnosis  will  have  to  be 
made  by  excluding  the  above-mentioned  causes  of  coma.  The 
diagnosis  from  acute  softening  is  discussed  on  p.  264. 

Cerebral  hemorrhage — prognosis  :  The  first  attack  is  in  most 
cases  recovered  from  ;  but  after  one  attack  there  is  always 
liability  to  another.  The  prognosis  becomes  worse  in  each 
succeeding  attack. 

Symptoms  of  bad  omen  are  :  profound  and  long  continuing 
coma  ;  coma  continuing  four  days  ;  an  initial  subnormal  or  a 
continued  elevated  temperature  ;  the  development  of  deli- 
rium ;  the  occurrence  of  the  attack  in  a  chronic  alcoholic  or 
subject  of  renal  disease  ;  development  of  bedsores  ;  and  con- 
tinuance of  loss  of  control  over  bowels  and  bladder.  Cere- 
bellar and  pons  hemorrhages  and  those  which  break  into  the 
ventricles  are  nearly  always  fatal.  As  regards  return  of 
function,  the  prognosis  is  fairly  good  if  contractures  have  not 
developed.  Otherwise  complete  recovery  does  not  occur. 
The  arm  usually  remains  the  most  affected. 

Cerebral  hemorrhage — treatment :  In  treating  the  attack  the 
patient  should  be  recumbent,  with  the  head  high,  and  it  is 
well  for  a  considerable  part  of  the  time  for  him  to  lie  on  his 
side.  The  room  should  be  quiet  and  darkened.  Ice  should 
be  applied  to  the  head  and  cloths  wrung  out  in  mustard  (cup- 
ful to  a  pail  of  water)  and  hot  water  wrapped  about  the  legs. 
In  a  robust  subject,  with  evidences  of  great  excitement  of  the 


262  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

circulation,  venesection  is  of  advantage.  In  other  cases  aco- 
nite or  bitter  veratrura  viride  should  be  given  until  the  heart's 
action  is  lessened.  A  purge,  consisting  of  one  or  two  drops 
of  croton  oil  or  elaterium  gr,  I,  should  also  be  administered. 
If  necessary,  the  patient  must  be  catheterized.  After  the 
first  few  hours  and  until  the  commencement  of  the  chronic 
stage,  the  treatment  consists  in  keeping  the  mouth  and  nasal 
passages  clean  with  antiseptic  solutions,  seeing  that  the  posi- 
tion is  changed  at  intervals,  and  meeting  such  symptoms  as 
may  arise. 

At  the  end  of  three  or  four  weeks,  the  muscles  may  be 
stimulated  with  the  faradic  current  and  massage.  If  con- 
tractures develop,  warm  baths  and  passive  movements  may 
be  helpful ;  the  functions  of  the  bowels  and  kidneys  regu- 
lated and  arterial  tension  kept  low  by  means  of  nitroglycerin 
if  necessary.  The  diet  should  be  simple  and  easily  digested, 
alcohol  avoided,  and  small  doses  of  iodide  of  potassium  com- 
bined with  tonics  employed.  If  possible,  a  warm,  equable 
climate  should  be  selected  as  a  place  of  residence,  and  the 
patient  should  always  be  cautioned  to  avoid  everything  that 
would  tend  to  elevate  the  blood-pressure. 

In  ingravescent  apoplexy  it  is  important  to  stop  the  hemor- 
rhage, for  if  it  breaks  into  the  ventricle,  as  it  will  eventually 
if  not  checked,  death  ensues.  For  this  purpose  the  common 
carotid  has  been  tied  with  success  in  a  few  instances. 


ACUTE  SOFTENING  OF    THE  BRAIN. 

Etiology  :  Acute  softening  is  caused  by  the  sudden  plugging 
of  a  vessel  by  an  embolus  or  thrombiis. 

Embolism  occurs  oftenest  between  the  ages  of  twenty  and 
fifty ;  and  the  predisposing  causes  are  endocarditis,  acute  in- 
fectious diseases,  profound  anaemia,  pregnancy,  and  blood 
dyscrasias. 

Thrombosis  is  most  frequent  between  the  ages  of  fifty  and 
seventy.  The  predisposing  causes  are  syphilitic,  lead,  or  gouty 
arteritis,  fatty  heart,  and  blood  dyscrasias. 

Acute  softening  of  the  brain — symptoms :  In  embolism  the 
onset  is  usually  sudden,  and  is  characterized  by  a  brief  period 
of  slight  convulsive  twitchings,  followed  by  loss  of  conscious- 


ACUTE  SOFTENING   OF  THE  BRAIN.  263 

ness  and  hemiplegia.  Coma  may  be  absent,  and  when  pres- 
ent is  of  briefer  duration  than  in  hemorrhage.  There  are 
either  no  or  very  slight  temperature-changes. 

In  thromboHk  prodromes  are  common.  They  consist  of 
headaches,  vertigo,  numbness  of  the  extremities,  drowsiness, 
and  in  syphilitic  cases  of  transient  paralyses,  especially  of  the 
eye-muscles.  The  onset  is  gradual,  it  taking  several  hours, 
or  even  longer,  for  the  hemiplegia  to  develop.  The  patient 
may  not  lose  consciousness,  and  if  he  does  it  is  also  apt  to 
develop  gradually.  The  attacks,  however,  may  be  sudden. 
They  frequently  occur  during  sleep.  The  temperature  usu- 
ally falls  slightly,  followed  by  a  rise;  but,  as  a  rule,  the  differ- 
ence between  that  of  the  paralyzed  and  the  normal  side  is  not 
so  great  as  in  hemorrhage.  The  resulting  hemiplegia  possesses 
the  same  general  characteristics  as  that  due  to  hemorrhage.  It 
is  apt  to  improve  quicker,  for  the  reason  that  the  paralysis  is 
usually  due  to  plugging  of  one  of  the  middle  cerebrals,  and 
as  the  cortical  arteries  anastomose  to  some  extent,  a  collat- 
eral circulation  is  formed.  In  thrombosis  mental  symptoms 
similar  to  those  occurring  after  hemorrhage  are  apt  to  fol- 
low. Thrombosis  occurs  in  the  vertebral,  basilar,  and  pos- 
terior cerebral  arteries  oftener  than  does  hemorrhage  from 
them.  The  symptoms  of  plugging  of  a  vertebral  artery  are 
those  of  an  acute  bulbar  palsy.  When  the  basilar  is  occluded, 
the  symptoms  are  similar  to  those  due  to  pontine  hemorrhage. 
If  the  main  trunk  of  a  posterior  cerebral  is  blocked,  hemi- 
anopsia with  sensory  aphasia  would  result ;  hemiansesthesia 
would  also  be  present,  as  this  artery  supplies  the  posterior 
part  of  the  internal  capsule. 

Acute  softening  of  the  brain — morbid  anatomy  and  path- 
ology :  Soon  after  the  vessel  is  plugged,  degeneration  and 
softening  of  the  area  supplied  by  it  begin.  If  a  terminal 
artery,  there  may  be  infarction,  either  hemorrhagic,  in  which 
the  territory  is  infiltrated  with  blood ;  or  a.ncemic,  in  which 
the  area  is  pale,  swollen,  and  necrotic.  The  nerve-fibres 
degenerate  and  become  fatty ;  the  neuroglia  sw^ollen  and 
cedematous.  In  the  cortex  the  softened  area  is  at  first  red  in 
color  (red  softening),  changing  to  yellow  (yellow  softening). 
In  the  white  matter  the  area  is  white  in  color,  containing  a  few 
red  punctate  spots.     Inflammatory  changes  are  common  in 


264  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

and  about  the  softened  area.  The  degenerated  tissue  is  grad- 
ually absorbed  :  if  small,  a  scar  results  ;  if  large,  a  cyst. 

If  an  embolus  is  derived  from  an  infected  focus,  as,  for  in- 
stance, an  ulcerative  endocarditis,  an  abscess  may  result. 

In  thrombosis  there  are  usually  evidences  of  atheroma  or 
syphilitic  arteritis. 

Secondary  degenerations  occur  as  in  hemorrhage. 

Acute  softening  of  the  brain — diagnosis :  When  the  coma  is 
gradual  in  its  onset  the  condition  is  not  apt  to  be  mistaken 
for  any  of  the  causes  of  coma  mentioned  under  hemorrhage, 
excepting  possibly  that  due  to  syphilitic  meningitis.  Here, 
and  also  in  those  cases  that  are  sudden  in  onset,  the  same 
rules  of  diagnosis  apply  as  were  stated  for  hemorrhage.  It 
is  important  when  possible,  which  it  sometimes  is  not,  to  dis- 
tinguish between  acute  softening  and  hemorrhage.  The  fol- 
lowing table  will  prove  useful : 


Hemorrhage. 


Age,  thirty  to  forty ;  sudden  onset, 
with  deep  coma  and  paralysis ; 
early  rigidity ;  unequal  pupils ; 
stertorous  breatlnng ;  pulse  slow, 
full,  and  hard  ;  conjugate  deviation 
of  the  eyes ;  temperature  higher 
on  the  paralyzed  side. 


Acute  Softening. 


Age,  either  before  thirty  or  after 
forty  ;  previous  history  of  syphilis ; 
prodromes;  gradual  onset  (throm- 
bosis) ;  coma  often  absent  or  tran- 
sitory ;  heart's  action  weak  (throm- 
bosis), or  endocarditis  present 
(embolism). 


Acute  softening  of  the  brain — prognosis :  The  prognosis  as 
regards  recovery  from  the  attack  is  somewhat  better  than  in 
hemorrhage.  When  due  to  embolism  recurrence  is  not 
likely,  but  the  reverse  obtains  when  thrombosis  is  the  cause. 
Recovery  from  the  attack  is  usually  more  cf)niplete  in  soften- 
ing than  in  hemorrhage. 

Acute  softening  of  the  brain — treatment :  The  treatment  of 
the  attack  cousists  of  rest,  attention  to  the  bowels  and  kid- 
neys, heart  stimulauts  and  arterial  dilators,  as  alcohol,  stro- 
phanthus,  and  nitroglycerin.  If  a  history  of  syphilis  is 
obtained,  vigorous  antisyphilitic  treatment  should  be  insti- 
tuted. 

The  treatment  of  the  chronic  stage  is  similar  to  that  of 
hemorrhage. 


ACUTE  HEMORRHAdIC  ENCEl'lIALlTIS.  265 


ACUTE  HEMORRHAGIC  ENCEPHALITIS. 

Definition— varieties :  This  term  is  u|)|)Ii('(l  to  a  syinpfoin- 
complex  due  to  foci  of  infianimation  scattered  thr()iiii:lioiit  the 
brain  and  which  are  not  accompanied  by  sii})})uratioii. 

The  gray  matter  of  the  cortex  may  ah)ne  be  affected — the 
polio-encephalitis  of  Striimpell,  who  believes  that  a  certain 
number  of  cases  of  cerebral  palsy  in  children  are  due  t.»  en- 
cephalitis localized  in  the  motor  region. 

The  gray  matter  about  the  aqueducit  of  Sylvius,  with  in- 
volvement of  the  nuclei  of  the  motor  nerves  of  the  eye,  may 
be  the  seat  of  the  process,  the  so-called  polio-encephalitis  su- 
perior of  Wernicke.  The  process  may  be  confined  to  the 
gray  matter  of  the  floor  of  the  fourth  ventricle,  involving  the 
nuclei  of  the  other  motor  cranial  nerves,  and  this  form  is 
known  as  polio-encephalitis  inferior  (pp.  119  and  211 ).  These 
forms  may  be  combined. 

Etiology :  The  chief  causes  are  chronic  alcoholism  and  the 
acute  infectious  diseases,  especially  influenza.  Cases  have 
also  been  attributed  to  poisoning  by  lead  and  ptomains,  and 
to  trauma,  the  latter  possibly  acting  by  lowering  the  resisting 
power  to  pyogenic  organisms.  It  is  more  common  in  children 
and  young  adults. 

Acute  hemorrhagic  encephalitis — symptoms  :  The  symptoms 
of  polio-encephalitis  superior  and  inferior  having  already  been 
discussed  (Ophthalmoplegia  and  Bulbar  Palsy),  those  due  to  a 
combination  of  these  and  Striimpell's  form  only  are  here 
described. 

There  may  be  a  prodromal  stage  of  headache,  vertigo,  and 
general  malaise ;  or  it  may  begin  suddenly  with  vomiting, 
restlessness,  stupor,  and  slight  rigidity  of  the  neck.  The 
temperature  may  either  not  rise  much  above  normal,  or  there 
may  be  an  initial  chill  followed  by  high  fever.  Res]ii ration  is 
usually  rapid. 

The  focal  symptoms  depend  upon  the  location  of  the  lesions. 
They  do  not  all  develop  at  the  same  time,  but  appear  at  in- 
tervals as  the  disease  progressively  attacks  different  regions. 
There  may  be  paralysis  of  some  or  all  of  the  ocular  nmscles  ; 
optic  neuritis  ;  paralysis  of  the  muscles  of  the  face  ;  throat ; 
tongue;  choreiform  movements  of  the  limbs;  paralysis  of  a 


266  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

hemiplegic  or  monoplegic  type ;  hemiansesthesia,  ataxia  or 
hemiataxia ;  conjugate  deviation  of  the  eyes  and  aphasia.  Of 
course,  all  of  these  symptoms  are  not  present  in  every  case, 
but  they  occur  in  different  combinations  in  different  cases. 

Morbid  anatomy :  Scattered  throughout  the  brain  are  foci 
of  inflammation,  characterized  by  hypersemia,  hemorrhage, 
serous  exudation,  and  round-cell  infiltration.  Suppuration 
never  occurs.  They  appear  as  red  or  yellow  points.  The 
small  bloodvessels  have  degenerated  walls  and  are  surrounded 
by  blood-corpuscles  and  round  cells.  The  nerve-cells  are 
swollen  and  may  finally  degenerate.  The  bloodvessels  are 
probably  the  starting-point  of  the  process,  the  changes  being 
similar  to  those  which  occur  in  acute  poliomyelitis. 

Diagnosis :  The  disease  may  be  mistaken  for  meningitis. 
It  differs  from  this  in  the  more  sudden  onset  of  stujoor, 
absence  of  markedly  contracted  pupils,  hypersesthesia,  and 
great  muscular  rigidity.  The  diagnosis  may,  however,  be 
very  difficult.  The  symptoms  described  following  infectious 
disease  or  occurring  in  a  chronic  alcoholic,  would  point  to  en- 
cephalitis. Cerebral  syphilis  is  distinguished  usually  by 
more  gradual  onset  and  other  evidences  of  the  disease. 

The  prognosis  is  grave  ;  but  cases,  especially  those  following 
infections  diseases,  recover.  Those  which  do  recover  have 
often  some  permanent  paralysis  remaining. 

Treatment  consists  of  purgation  with  calomel  and  applica- 
tion of  ice-bags  to  the  head.  If  there  is  much  restlessness, 
bromides  or  other  sedatives  are  indicated.  If  the  patient  is 
debilitated,  stimulants  should  be  given.  Lumbar  puncture 
has  been  advised  w^here  there  is  much  intracranial  pressure. 
In  the  period  of  convalescence,  tonics  and  treatment  to  restore 
the  paralyzed  muscles. 

Acute  Suppurative  Encephalitis  (Abscess). 

Etiology :  Suppuration  of  the  brain-substance  practically 
always  is  due  either  to  extension  of  inflammation  from  neigh- 
boring parts  or  infection  from  a  distance  through  the  blood. 
The  chief  causes  are,  in  the  order  of  their  importance : 

(1)  Extension  from  disease  of  the  middle  ear  or  mastoid 
cells,  which  may  be  by  passing  of  the  infection  from  the  roof 


ACUTE  SUPPURATIVE  ENCEPHALITIS.  267 

of  the  mastoid  antrum  to  the  sigmoid  sinus,  where  an  infec- 
tive thrombosis  is  produced  ;  by  involvement  of  the  dura  and 
the  formation  of  a  subdural  abscess  which  extends  to  the 
arachnoid  and  pia  mater ;  by  extension  of  inflammation  along 
the  lymph-spaces  or  thrombosed  veins  into  the  brain-substance. 

(2)  Traumatism  to  the  head,  with  or  without  abrasion  of 
the  skin,  and  usually  associated  with  fracture  of  the  skull. 

(3)  Remote  septic  processes,  as  ulcerative  endocarditis, 
tuberculosis  of  the  lungs,  fetid  bronchitis,  empyema,  suppu- 
ration of  the  liver,  localized  caries  of  the  ethmoid,  nasal 
bones,  and  of  the  orbit,  and  pyaemia. 

(4)  The  infectious  fevers,  especially  influenza,  are  occasional 
causes. 

Most  cases  occur  between  ten  and  thirty.  Males  are  more 
frequently  attacked  than  females. 

Abscess  of  the  brain — symptoms:  Abscesses  of  the  brain 
may  run  either  a  rapid  or  a  slow  course.  The  former  usually 
follow  trauma,  and  the  symptoms  may  be  general  or  focal. 
The  general  symptoms  are,  following  an  injury,  severe  head- 
ache, vomiting,  rigors,  irregular  fever,  mental  dulness,  and 
delirium.  If  there  are  no  focal  symptoms,  which  is  some- 
times the  case,  the  condition  may  be  mistaken  for  meningitis. 
When  they  are  present  they  consist  of  paralysis,  usually  of 
the  hemiplegic  type  ;  aphasia,  epileptiform  convulsions,  and, 
if  in  the  cerebellum,  cerebellar  inco5rdination.  Optic  neuritis 
may  occur.  The  pulse  is  usually  slow,  60-70.  The  mental 
dulness  is  succeeded  by  coma,  and  death  occurs  from  exhaus- 
tion in  from  a  few  days  to  a  month  after  the  onset. 

The  chronic  form  most  commonly  follows  ear  disease. 
After  the  abscess  has  formed  the  symptoms  may  remain 
practically  latent  for  weeks,  months,  or  even  years.  During 
this  period  the  patient  may  suffer  from  headache,  vertigo, 
and  mental  depression.  Occasionally  there  may  be  acute 
exacerbations  associated  with  severe  headache,  vomiting,  and 
delirium  or  convulsions,  after  which  the  patient  returns  to 
his  former  state  of  health.  The  temperature  is  normal  or 
subnormal.  When  the  terminal  stage  sets  in,  either  symp- 
toms similar  to  those  of  the  acute  form  described  above 
appear,  or  there  is  a  sudden  epileptic  seizure  or  a  rapid  devel- 
opment of  coma,  in  which  death  soon  occurs. 


268   DIFFUSE  AND  LOCAL  DISEASES   OF  THE  BRAIN. 

Phlebitis  of  the  superior  petrosal  and  lateral  sinuses  may 
coexist,  especially  in  tliose  cases  due  to  ear  disease.  When 
present,  redenia  al)()ut  the  ear  and  neck  and  hardness  of  the 
jugular  veins  will  be  manifest.  Meningitis  may  also  be 
present,  and.  would  usually  be  indicated  by  rigidity  of  the 
neck,  hypersesthesia,  and  possibly  paralyses  of  the  cranial 
nerves. 

Abscess  of  the  brain — morbid  anatomy  :  The  abscess  may 
be  solitary  or  multiple,  most  frequently  the  former,  and  may 
be  produced  by  any  one  of  the  pyogenic  bacteria.  In  acute 
cases  the  suppuration  is  not  limited,  but  in  chronic  cases  the 
abscess  is  enclosed  in  a  capsule.  In  acute  cases  the  pus  is 
reddish  in  color  and  is  mixed  with  softened  brain-matter.  In 
the  chronic  cases  it  is  of  greenish  tint,  acid  reaction,  and 
peculiar  odor,  resembling  somewhat  that  of  sulphuretted 
hydrogen.  The  brain-substance  about  the  abscess  is  usually 
oedematous.  The  size  varies  from  that  of  a  walnut  to  that 
of  an  orange.  Abscesses  occur  most  frequently  in  the  cere- 
brum, usually  on  the  right  side,  and  in  either  the  temporal 
or  the  frontal  lobe.  Those  due  to  ear  disease  are  nearly 
always  either  in  the  tempoi'al  lobe  or  cerebellum. 

Diagnosis  :  The  diagnosis  of  abscess  of  the  brain  is  often 
difficult.  It  is  based  upon  the  occurrence  of  the  symptoms 
as  detailed  above,  coming  on  after  head-injury  or  the  previous 
occurrence  of  aural  or  nasal  disease,  or  any  of  the  causes  men- 
tioned under  etiology. 

In  abscess  the  pulse  is  slow  ;  an  increase  in  the  pulse-rate 
coincident  with  elevation  of  temperature  makes  its  diagnosis 
doubtful. 

Phlebitis,  and  consequent  thrombosis,  of  the  lateral  and 
petrosal  sinuses  may  occur  independently  of  abscess.  Its 
presence  would  be  distinguished  by  the  symptoms  mentioned 
above. 

The  location  of  the  abscess  is  based  upon  the  presence  of 
symptoms  pointing  to  interference  with  the  functions  of  that 
part  of  the  brain  where  the  abscess  is  situated  (see  Cerebral 
Localization).  They  often  occur,  however,  in  silent  regions, 
in  which  case  localizing  symptoms  would  be  absent. 

The  diagnosis  may  have  to  be  made  from  tumor  and  men- 
ingitis (p]).  180  and  280),     The  differential  points  are  given 


TUMORS  OF  THE  BRAIN.  269 

under  the  description  of  tliose  diseases.  Meningitis  may, 
however,  be  associated  with  abscess. 

Abscess  of  the  brain — prognosis — treatment :  The  pruynosis 
is  bad.  Cases  do  recover  if  surgical  interference  is  resorted 
to  in  time.  In  a  few  instances  evacuation  has  taken  place 
spontaneously  through  the  nasal  passages  ;  but  the  majority 
die. 

The  treatment  is  trephining  over  the  seat  of  the  abscess  and 
evacuating  it. 

TUMORS  or  THE  BRAIN. 

Etiology :  In  a  small  percentage  of  cases  a  history  of  a 
blow  or  fall  upon  the  head  has  been  obtained.  Males  are 
more  subject  to  brain-tumor  than  females.  They  occur  in 
persons  of  all  ages. 

Tumor  of  the  brain — varieties  :  Almost  every  known  variety 
of  tumor  has  been  found  in  the  brain.  Certain  ones  are  com- 
mon, while  others  are  rare.  Those  whicli  are  common,  in  the 
order  of  frequency,  are  tubercular  tumors,  sarcoma,  glioma, 
glio-sarcoma,  cyst,  carcinoma,  and  gumma.  The  rare  ones 
are  fibroma,  angioma,  myxoma,  osteoma,  lipoma,  psammoma, 
cholesteatoma,  and  echinococcus  cyst. 

Tubercular  tumors  are  most  common  in  childhood  ;  they  may 
be  primary,  but  are  usually  secondary  to  tubercular  disease 
elsewhere.  They  are  often  (20  per  cent.)  multiple.  Their  size 
varies  from  a  small  collection  of  miliaiy  tubercles  lying  in  a 
mass  of  thickened  pia  mater  to  a  large,  solid  circumscribed 
mass,  with  a  hard,  cheesy,  or  broken-down  granular  centre 
and  a  distinct  capsule.  They  may  be  found  within  the  cere- 
bral tissue  at  some  distance  from  the  surface,  but  are  usually 
found  in  connection  with  the  meninges  and  large  cerebral  ves- 
sels ;  hence  are  upon  the  surface  or  at  the  base.  Tubercular 
meningitis  may  coexist. 

Sarcoma  rarely  occurs  secondarily  to  sarcoma  elsewhere  in 
the  body.  Frequently  there  may  be  more  than  one  present. 
The  tumor  is  usually  encaj)su]ated,  hard  in  consistency,  and 
is  easily  separated  from  the  brain-substance,  which  it  i-arely 
infiltrates;  that  it  does  so  occasionally  must  be  reineml)ere(l. 
It  grows  rapidly  and  is  not  \':isculjir.      Any  part  of  the  brain 


270  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

may  be  the  seat  of  sarcoma,  but  it  is  more  frequent  in  the 
cortex  and  cerebellum. 

Glioma  is  usually  primary.  They  are  softer  in  consistency 
than  sarcoma  and  usually  infiltrate  the  brain-substance.  They 
have  a  marked  tendency  to  become  cystic.  They  may  appear 
in  any  part  of  the  brain,  but  are  more  frequent  in  the  white 
matter.  As  a  glioma  grows,  it  destroys  the  nerve-tissue  and 
does  not  compress  it  as  sarcoma  does.  It  is  a  vascular  tumor, 
and  renders  the  patient  liable  to  apoplectiform  attacks. 

Glio-sarcoma  partakes  of  the  nature  both  of  sarcoma  and 
glioma.  It  is  often  cystic,  and  is  not  encapsulated.  The 
symptoms  resemble  those  of  glioma. 

Carcinoma  is  usually  secondary  to  carcinoma  elsewhere.  It 
is  most  common  in  adults  above  the  age  of  fifty.  It  grows  rap- 
idly, infiltrates  the  brain-substance,  and  is  very  vascular. 

Cystic  tumors  may  be  the  result  of  cystic  degeneration  oc- 
curring in  a  glioma  or  glio-sarcoma ;  or  as  the  result  of  in- 
fection with  the  echinococcus.  The  latter  are  rare  in  this 
country. 

Gumma  is  rare  in  childhood.  It  does  not  occur  as  the  re- 
sult of  inherited  syphilis.  It  may  occur  any  time  from  one 
to  twenty  years  or  more  after  the  primary  infection.  Gumma 
may  occur  either  as  a  soft,  gelatinous  mass  anywhere  in  the 
membranes,  most  commonly  at  the  base  ;  or  as  a  harder,  cir- 
cumscribed tumor  in  the  meninges,  usually  involving  the  cor- 
tex or  cerebellum.     The  growth  is  rapid. 

The  remaining  varieties  of  tumor  are  of  great  rarity ;  they 
may  occur  in  either  children  or  adults, 

A  brain  in  wMch  tumor  has  developed  usually  presents 
the  following  characteristics  :  The  membranes  are  tense,  ow- 
ing to  pressure  the  convolutions  are  flattened,  the  ventricles 
are  distended  with  serous  fluid,  the  brain-tissue  is  wet,  the 
weight  of  the  brain  is  increased,  and  frequently  there  will  be 
found  about  the  tumor  a  zone  of  softening. 

Tumor  of  the  brain — symptoms :  The  symptoms  may  be 
divided  into  two  classes  : 

(1)  General  symptoms,  which  occur  independently  of  the 
position  of  the  tumor  ; 

(2)  Focal  symptoms,  or  those  dependent  upon  interference 


TUMORS  OF  THE  BRAIN.  271 

with  the  functions  of  the  cerebral  centres  or  of  the  tracts 
which  run  to  or  from  them. 


General  Symptoms. 

These  depend  upon  the  rapidity  of  growth,  vascularity,  and 
variety  of  the  tumor.  They  vary  in  severity  from  time  to 
time.  For  instance,  while  the  tumor  is  growing  rapidly  they 
may  be  severe  ;  if  it  becomes  stationary  for  a  time,  they  may 
almost  disappear.  They  are  also  influenced  by  agents  which 
produce  a  temporary  cerebral  anaemia  or  hypersemia.  Such 
are  headache,  general  convulsions,  optic  neuritis,  secondary 
optic  atrophy,  changes  in  the  disposition  and  mental  power, 
vomiting,  vertigo,  insomnia,  changes  in  the  pulse-rate,  attacks 
of  syncope,  apoplectiform  attacks,  polyuria,  and  progressive 
emaciation. 

Headache  is  a  most  constant  symptom  ;  it  is  usually  in- 
tense. It  may  be  either  dull,  heavy,  and  continuous,  with 
sharp  paroxysms ;  or  it  may  be  intermittent.  It  is  increased 
by  physical  or  mental  strain  or  emotional  excitement.  If 
gumma  is  present,  it  is  usually  worse  at  night.  In  addition  to 
the  pain,  there  may  be  indefinite  sensations,  as  fulness,  press- 
ure, tightness  as  if  a  band  were  about  the  head.  The  loca- 
tion of  the  pain  is  usually  frontal  or  occipital,  and  rarely  has 
any  relation  to  the  location  of  the  tumor. 

The  causes  of  the  headache  are  increase  of  the  intracranial 
pressure  and  consequent  stretching  of  the  membranes,  or  the 
direct  involvement  of  the  dura  and  consequent  irritation  of 
the  branches  of  the  fi^fth  nerve. 

General  convulsions  are  particularly  liable .  to  occur  as  an 
early  symptom  in  children,  but  may  be  the  first  symptom  in 
adults.  They  may  occur  at  intervals  for  some  time  previous 
to  the  development  of  other  symptoms,  and  are  of  an  epilep- 
tiform nature.  Special  attention  should  be  paid  to  the  loca- 
tion and  nature  of  the  aura  (see  Jacksonian  Epilepsy). 

The  occurrence  of  general  convulsions  is  indicative  of 
rapid  growth  of  the  tumor  and  has  no  localizing  value. 
Death  frequently  occurs  in  a  convulsion. 

Changes  of  disposition  and  mental  power  occur  with  con- 
siderable frequency  in  the  course  of  brain-tumor  independently 


272   DIFFUSE  AND  LOCAL  DISEASES   OF  THE  BRAIN. 

of  the  situation,  but  are  more  marked  in  those  of  the  frontal 
lobes.  Children  become  fretful  and  irritable,  refuse  to  play, 
and  lose  interest  in  things  which  formerly  attracted  them. 
Often  they  prefer  to  keep  quiet  and  secluded,  and  may  be- 
come somnolent  and  lethargic.  In  adults  the  individual 
loses  interest  in  his  business  and  surroundings ;  he  be- 
comes apathetic,  and  may  sit  in  one  place  for  hours  doing 
nothing ;  if  aroused,  he  may  answer  questions  intelligently  ; 
finally,  however,  as  the  case  progresses,  the  memory  is  lost 
and  dementia  appears.  Attacks  of  maniacal  excitement  may 
occur  and  delusions  develop.  Any  of  the  manifestations  of 
hysteria  may  occur. 

Optic  neuritis  and  atrophy :  The  optic  neuritis  is  usually 
of  the  type  familiarly  known  as  choked  disc,  and  is  a  most 
important  symptom.  A  severe  form  of  neuritis  may  exist 
without  defect  of  sight ;  hence  the  eye-ground  should  always 
be  examined  in  all  cases  presenting  cerebral  symptoms  (see 
Diseases  of  Optic  Nerve). 

Optic  atrophy,  if  found,  is  the  result  of  a  previous  neuritis. 
Optic  neuritis  occurs  in  about  80  per  cent,  of  brain-tumors, 
and  is  more  frequent  in  tumors  of  the  base  and  in  the  region 
of  the  basal  ganglia  and  in  the  cerebellum  than  in  those  of 
the  cortex  and  centrum  ovale.  According  to  Marcus  Gunn,* 
the  condition  of  the  optic  nerves  may  aid  in  the  localization 
of  a  tumor  to  the  following;  extent : 

(1)  An  intense  double  optic  neuritis,  with  much  swelling 
and  surrounding  retinal  change,  coming  on  quickly,  suggests 
the  cerebellum. 

(2)  One-sided  optic  neuritis,  or  marked  difference,  suggests 
the  cerebrum ;  and  is,  on  the  whole,  in  favor  of  the  tumor  being 
on  the  same  side  as  the  excess  of  neuritis,  when  there  are 
other  reasons  for  localizing  one  in  the  front  of  the  cerebrum. 

Vomiting  is  rather  more  common  in  children.  It  may  or 
may  not  be  accompanied  by  nausea,  and  occurs  independently 
of  the  taking  of  food.  Attacks  are  frequent  in  the  morning 
just  before  rising,  and  often  at  such  times  the  slightest  move- 
ment of  the  head  is  sufficient  to  provoke  a  paroxysm. 

Vertigo  may  occur  with  or  independently  of  vomiting.  It 
is  often  excited  by  changes  in  ]K)sition,  and  the  attacks  are 
^  Brain,  p.  3o7,  KSys. 


TUMORS   OF  THE  BRAIN.  27P. 

paroxysmal.  It  is  most  common  with  tumors  in  the  posterior 
fossa,  cerebellum,  pons,  or  on  the  base  involving  the  auditory 
nerve. 

Insomnia  is  most  frequently  complained  of  by  adults,  espe- 
cially those  suffering  from  syphilitic  growths. 

Syncope  is  sometimes  an  occasional  symptom  in  tumors  of 
the  posterior  fossa. 

Polyuria,  with  or  without  glycosuria,  may  develop  in  the 
course  of  brain-tumor  as  a  symptom  of  increased  pressure. 
It  has  also  occurred  in  small  tumors  of  the  medulla  and  cere- 
bellum, probably  due  to  irritation  of  the  nucleus  of  the 
vagus. 

Tumor  of  Brain — Focal  Symptoms. 

These  depend  upon  the  location  of  the  tumor  ;  when  it  is 
situated  in  one  of  the  so-called  "■  silent  regions'"  of  the  brain 
they  are  practically  absent.  Focal  symptoms  are  due,  first, 
to  the  irritation  or  destruction  of  the  centre  in  which  it  is  situ- 
ated ;  and,  second,  to  either  irritation  of  neighboring  centres 
or  to  loss  of  their  functions  due  to  pressure.  Thus  a  tumor 
situated  so  as  to  destroy  the  left  third  frontal  convolution, 
producing  aphasia,  would  also  in  time,  by  the  pressure  it  ex- 
cited upon  them,  destroy  the  functions  of  the  motor  centres 
at  the  foot  of  the  central  convolutions.  The  reader  is  referred 
to  Cerebral  Localization  for  information  regarding  the  situa- 
tion and  functions  of  the  cortical  centres,  and  the  functions  of 
the  basal  ganglia,  pons,  medulla,  and  cerebellum.  Fig.  4 
shows  the  course  and  relations  of  the  projection-fibres,  and 
Fig.  54  the  situation  and  relations  of  the  cranial  nerves  at 
the  base  of  the  brain. 

A  knowledge  of  the  situation  and  anatomical  relations  of 
these  centres,  tracts,  and  nerves  is  essential  to  interpret 
properly  focal  symptoms. 

A  slow-growing  tumor  wliich  does  not  infiltrate,  but  grad- 
ually compresses,  the  brain  may  not  cause  such  symptoms 
until  it  has  readied  large  size,  for  nervous  tissues  often  ac- 
custoni  themselves  to  gradually  exerted  pressure. 

The  usual  combination  of  focal  symptoms  in  the  more 
commonly  affected   parts  of  tlie  brain  are  as  follows  : 

Frontal  lobes :  The  focal  symptoms  wlien  the  cortex  of  the 
18— N.  D. 


274  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

Fig.  54. 


The  base  of  the  brain  and  the  cranial  nerves,  crura,  pons  and  medulla  (Allen  Thomp- 
son;, /to  XII,  the  cranial  nerves  ;  T/j,  optic  thalamus ;  A,  pituitary  body ;  tc, 
tuber  cinereum  ;  a,  corpora  albicantia ;  P,  pes  pedunculi ;  j,  interinr  ;  aiid  c,  ex- 
terior, geniculate  body  ;  PV,  pons  Varolii ;  pa,  anterior  pyramid  of  medulla; 
o,  olive;  d,  decussation  of  anterior  pyramids;  oa,  anterior  column  of  spinal 
cord;  d,  lateral  column  of  spinal  cord;  Ce,  cerebellum ;  ^.,  flocculus  of  cere- 
bellum. 


frontal   lobes  are  involved  are  :   mental    inactivity,  lack  of 
judgment,  change  in  character,  irritability,  forgetfulness,  in- 


TUMORS   OF  THE  BRAIN.  275 

ability  to  concentrate  the  attention  and  to  think  continuously. 
They  are  not  present  in  growths  lying  upon  the  base  of  the 
frontal  lobe  in  the  orbital  bone.  Similar  symptoms  occur  in 
tumors  in  other  situations,  but  they  are  not  so  marked  nor 
occur  so  early.  There  may  be  loss  of  the  sense  of  smell, 
which,  if  one-sided,  is  probably  on  the  side  of  the  tumor. 
Tumors  involving  the  left  side  are  apt  to  cause  a  degree  of 
aphasia  more  or  less  marked.  Localized  spasms  and  paralysis 
may  be  also  present. 

Motor  region :  Cortical  tumors  cause  either  tonic  or  clonic 
convulsions,  occurring  at  intervals.  These  may  be  either  lim- 
ited to  one  part  of  the  body  or  extend  from  the  part  first  affected 
to  other  parts  (Jacksonian  Epilepsy,  see  p.  337).  The  start- 
ing-point of  the  spasm  indicates  the  situation  of  the  growth. 
Such  spasms  are  usually  followed  by  a  temporary  paralysis, 
which  as  the  tumor  grows  becomes  permanent.  The  spasm 
may  be  preceded  by  tingling  and  numbness.  Permanent 
parsesthesia  indicates  a  tumor  behind  the  fissure  of  Rolando. 
Tumors  situated  beneath  the  cortex  of  the  motor  region  (sub- 
cortical) usually  cause  paralysis  without  spasm  ;  or  if  spasm 
finally  occurs  owing  to  extension  of  the  growth  to  the  cortex, 
it  is  preceded  by  paralysis.  Slight  degrees  of  anaesthesia  may 
be  found. 

Parietal  region :  Tumors  in  tliis  region  may  cause  disturb- 
ances of  sensation  and  muscle-sense  in  the  limbs  of  the  op- 
posite side.  Word-blindness  is  due  to  lesion  of  the  left  in- 
ferior parietal  lobe  (angular  and  supra-marginal  gyri),  as  is 
also  homonymous  hemianopsia. 

Occipital  region :  Tumors  here  produce  lateral  homony- 
mous hemianopsia,  in  which  Wernicke's  pupillary  inaction 
sign  is  not  present. 

When  the  cuneus  is  not  seriously  involved  (left  side)  there 
may  also  be  a  condition  known  as  mind-blindness,  in  which 
there  is  incapacity  to  understand  the  nature  of  things  seen 
(apraxia).  If  the  lesion  extends  into  the  parietal  lobe, 
hemiansesthesia,  hemiataxia,  and  some  hemiplegia  may  residt. 

Temporal  lobe :  Growths  involving  the  first  and  second 
temporal  convolutions  of  the  left  side  (in  a  right-handed 
person)  cause  word-deafness.  Tumors  in  other  parts  of  this 
lobe  produce  no  definite  symptoms,  those  present  being  due 


276   DIFFUSE  AND  LOCAL   DISEASES  OF  THE  BRAIN. 

to  pressure  upon  the  motor  tract  or  the  temporal  convolutions 
above  mentioned. 

Tumors  of  the  corpus  callosum  are  rare.  They  cause  mental 
symptoms  similar  to  those  produced  by  involvement  of  the 
frontal  lobes,  often  followed  by  a  double  hemiplegia,  one 
side  being  affected  before  the  other. 

Tumors  of  the  corpus  striatum  produce  no  recognizable 
symptoms  excepting  those  due  to  pressure  upon  either  the 
motor  or  the  sensory  tracts,  usually  the  motor,  passing  through 
the  internal  capsule.     If  these  tracts  become  involved  suc- 

FiG.  55. 


The'three  peduncles  of  the  cerebellum  (from  Hirschfeld  and  Sappey). 

1,  rhomboidal  fossa  of  the  fourth  ventricle ;  %  stria:  acousticEe ;  3,  inferior  pedun- 
cles, or  restiform  bodies  ;  4,  columns  of  Goll :  5,  superior  cerebellar  peduncles  ; 
6,  lemniscus  ;  7,  middle  peduncles ;  8,  corpora  quadrigemina. 


cessively,  it  would  be  evidence  of  the  existence  of  a  tumor 
in  this  region  (see  Fig.  46). 

In  tumors  of  the  optic  thalamus  there  may  be  mental  stu- 
pidity, nystagmus,  and  weakness  of  ocular  movements  on 
the  side  of  the  tumor  ;  hemiansesthesia  and  weakness  of  limbs 
upon  the  opposite  side,  athetoid  and  incoordinate  movements. 
If  in  the  posterior  part,  there  is  hemianopsia  with  Wernicke's 


TUMORS  OF  THE  BRAIN. 


277 


hemiopic  pupillary  inaction   sign    present,     Tlie  diagnosis    is 
always  un(^ertain. 

Tumors  of  the  corpora  quadrigemina,  owing-  to  their  prox- 
imity to  the  cerebellum,  cause  disorders  in  gait  similar  to 
cerebellar  disease  (Fig.  55),  and  paresis  of  the  motor  nerves  of 
the  eye  (Fig.  27),  the  usual  type  being  that  of  ophthalmople- 

FiG.  56. 


yju 

Post. 


Diagram  of  section  through  lower  part  of  pons.  This  diagram  is  not  quite  accu- 
rate, as  it  represents,  for  convenience,  certain  structures  which  are  not  actually 
observed  at  exactly  the  same  level.  (Thus  it  shows  the  origin,  course,  and  exit 
of  the  seventh  nerve.)  VI,  abducens  nerve  and  nucleus ;  N  VIJ,  nucleus  of 
facial  nerve:  T'JJ,  facial  nerve;  VIII  Ant.  nn(i  F/7/ Po.«<.,  anterior  and  poste- 
rior or  deep  and  superficial  roots  of  the  auditory  nerve;  Corp.  Red.,  restiform 
body;  A'?iee,  knee  of  the  facial  nerve  :  O.S.,  superior  olive  ;  P.  L.B.,  posterior  lon- 
gitudinal bundle  ;  S.T.F.,  superficial  transverse  fibres  of  the  pons  ;  D.T.F..  deep 
transverse  fibres  of  the  pons;  F.  ^sc,  ascending  root  of  trigeminus ;  Svb.  Gel., 
substantia  gelatinosa.  The  internal  of  "  chief"  auditory  nucleus  lies  just  inter- 
nal to  the  nucleus  of  Deiters. 


gia  externa.  There  may  also  be  hemianopsia  of  similar  type 
to  that  occurring  in  growths  involving  the  thalamus.  There 
may  also  be  some  dulness  of  hearing,  more  marked  in  the 
ear  opposite  the  lesion. 

A  tumor  involving  the  crus  would  cause  hemiplegia  of  the 
opposite  side,  with  third-nerve  paralysis  upon  the  same  side 
as  the  lesion  (Fig.  47). 

Tumors  of  the  pons  produce  symptoms  according  to  their 


278  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

size  and  location.  If  sitnated  high  up,  a  crossed  paralysis 
similar  to  that  produced  by  a  lesion  of  the  crus  would  result. 
If  a  little  lower  down,  motor  and  sensory  paralysis  of  the 
arm  and  leg  on  the  opposite  side,  with  paralysis  (sensory  por- 
tion) of  the  fifth  nerve  on  the  same  side  as  the  lesion.  In 
the  lower  part  hemiplegia  upon  the  opposite  side,  with  paralysis 
of  the  seventh  nerve  upon  the  side  of  the  lesion.  Also 
in  this  location  the  sixth  and  eighth  nerves  may  be  in- 
volved with  the  seventh  (Fig.  56).  Crossed  hemiansesthesia 
may  be  associated  with  the  hemiplegia,  and  varies  in  degree 
of  completeness  according  to  the  location  of  the  lesion  (Fig. 
57).     If  on  the  lateral  edge  involving  the  peduncles,  forced 

Fig.  57. 


Crossing  of 
Sensory  Tract 

Diagram  illustrating  the  mechanism  of  crossed  anesthesia  (after  Starr).  Any  lesion 
interrupting  the  general  sensory  tract  from  the  lines  above  the  crossing  of  this 
tract  in  the  medulla  and  the  ascending  root  of  the  iifth  nerve  on  the  same  side, 
will  produce  crossed  ansesthesia.  The  conditions  w^ill  vary,  however,  with  the 
level  of  the  lesion.  Thus,  a  lesion  at  A  will  cause  typical"  crossed  anaesthesia 
and  rotation  of  the  body  to  the  side  of  the  lesion  frorti  involvement  of  the  mid- 
dle peduncle  of  the  cerebellum  ;  a  lesion  at  2J  will  cause  complete  angesthesia 
of  the  opposite  limbs  and  trunk,  but  the  auEesthesiaof  the  face  on  the  same  side 
as  the  lesion  will  not  involve  the  entire  face,  sensation  remaining  normal  in  its 
upper  portion  ;  a  lesion  at  C  will  cause  anaesthesia  of  the  entire  opposite  half  of 
the  body,  but  probably  only  partial  and  greatly  limited  ansesthesia  of  the  face 
on  the  same  side  as  the  lesion. 


movements  will  result.  There  may  also  be,  if  the  sixth  nu- 
cleus is  involved,  conjugate  deviation  of  the  eyes,  in  which 
the  eyes  look  away  from  the  side  of  the  lesion ;  when  this 
symptom  is  produced  by  cerebral  lesions,  the  eyes  look  toward 


TUMORS  OF  THE  BRAIN.  279 

the  side  of  the  lesion.  The  knee-jerks  are  frequently  absent. 
Tumor  of  the  medulla,  if  large,  would  produce  symptoms  of 
progressive  bulbar  palsy,  plus  more  or  less  hemiplegia  and 
hemiansesthesia.  If  a  small  growth,  crossed  paralysis  of  the 
hypoglossal  nerve  with  hemiplegia  may  occur  (see  Fig.  47). 

Tumors  of  the  cerebellum :  Tumors  in  the  middle  lobe  cause 
cerebellar  ataxia,  sometimes  called  titubation.  The  gait  of 
the  patient  is  staggering,  with  steps  of  irregular  length  and 
position,  like  that  of  a  drunken  man.  Forced  movements 
occur,  causing  the  patient  to  fall  either  sideways  or,  more 
rarely,  forward  or  backward.  Owing  to  pressure  on  the  me- 
dulla, polyuria  with  or  without  glycosuria  may  be  present ; 
also  disturbances  of  the  functions  of  the  cranial  nerves. 
Later,  hemiplegia  or  paraplegia,  due  to  pressure,  may  develop. 

A  tumor  may  exist  in  the  lateral  lobes,  if  near  the  surface, 
without  causing  symptoms  ;  but  when  it  is  situated  near  the 
median  line  or  invades  the  peduncles,  there  may  be  some  un- 
steadiness of  gait,  a  tendency  in  the  patient  to  fall,  usually 
away  from  the  side  of  the  tumor,  but  sometimes  toward  it. 
Hemiparesis  and  interference  with  the  functions  of  the  cra- 
nial nerves,  especially  the  seventh  and  eighth,  on  the  same 
side  as  the  tumor.  When  the  superior  peduncles  are  in- 
volved, there  is  paralysis  of  the  ocular  muscles,  the  symp- 
toms being  similar  to  those  of  tumor  of  the  corpora  quadri- 
gemina.  If  the  headache  in  cerebellar  tumor  is  occipital,  it  is 
usually  on  the  same  side  as  the  tumor ;  if  frontal,  it  is  on  the 
opposite  side.  The  relations  of  the  cerebellum  to  the  cranial 
nerves  and  projection-fibres  are  shown  in  Figs.  4  and  5.  The 
knee-jerks  in  cerebellar  tumor  are  usually  exaggerated,  but 
may  be  absent.  Often  in  the  early  stages  they  may  be  absent ; 
finally  reappearing  and  becoming  exaggerated. 

Tumors  of  the  base  of  the  brain  compress  one  or  more  of 
the  cranial  nerves  either  unilaterally  or  bilaterally,  according 
as  the  tumor  is  situated  on  oue  side  or  in  the  median  line  ; 
the  tumor  can  be  usually  determined  by  noticing  the  order  in 
which  the  nerves  become  involved ;  their  relations  to  each 
other  and  other  structures  at  the  base  of  the  brain  are  indi- 
cated in  Fig.  54. 

Tumors  which  destroy  the  hypophysis  produce  the  symp- 
toms of  acromegaly. 


280     DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

Tumors  of  the  Brain — Diagnosis. 

The  combination  of  two  or  more  of  the  general  symptoms 
mentioned  with  focal  symptoms  should  cause  a  strong  suspi- 
cion of  the  existence  of  a  brain-tumor;  the  diagnosis,  however, 
may  at  times  be  difficult ;  the  following  may  be  mistaken  for  it : 

Brain-abscess  produces  similar  symptoms  ;  but  they  usually 
develop  after  head-injuries;  or  a  history  of  the  previous  ex- 
istence of  suppuration  of  the  middle  ear  or  of  some  of  the 
other  causes  mentioned  in  the  etiology  of  brain-abscess  is 
obtainable. 

The  symptoms  develop  more  rapidly  and  with  greater 
severity  than  those  of  tumor,  and  there  may  be  fever. 
Headache  is  more  severe  and  optic  neuritis  is  more  apt  to  be 
present  in  tumor.  In  abscess,  after  the  appearance  of  symp- 
toms, they  may  disappear  for  some  time  ;  a  duration  of  one  to 
two  years,  in  which  symptoms  are  constantly  present,  indi- 
cates tumor. 

Tubercular  meningitis,  in  wdiich  the  symptoms  pursue  a 
chronic  course,  may  be  mistaken  for  tumor.  When  menin- 
gitis is  present,  the  headache  is  usually  more  severe  and  dif- 
fuse ;  hypersesthesia  of  the  skin  and  special  senses  is  more  apt 
to  be  present.  Optic  neuritis  is  not  so  frequent,  and  w^hen 
present  is  not  so  intense,  and  tubercles  upon  the  choroid  may 
be  present.  Irregular  but  persistent  fever  would  point  to 
meningitis.  It  must  be  remembered  that  the  two  may  coexist, 
in  which  case  the  diagnosis  might  be  impossible,  as  would  also 
be  the  case  when  the  meningitis  is  localized  to  a  small  area. 

Chronic  hydrocephalus  is  often  the  result  of  tumor,  espe- 
cially when  it  is  situated  in  the  cerebellum.  In  those  cases 
which  are  due  to  inflammation  of  the  ependyma  of  the  ven- 
tricles, the  general  symptoms  are  similar  to  those  of  tumor, 
but  the  local  symptoms  are  somewhat  different.  Spastic  par- 
alysis develops  without  spasm  and  is  always  bilateral.  The 
course  is  very  chronic  and  atrophy  of  the  cranial  bones  occurs  ; 
optic  neuritis  is  not  so  conniion. 

Apoplectic  attacks,  which  sometimes  occur  in  tumor,  are 
distinguislied  from  the  ordinary  cerebral  hemorrhage  by 
the  discovery  of  the  symptoms  of  tumor  after  those  of  the 
hemorrhage  have  subsided. 


TUMORS  OF  THE  BRAIN.  281 

Uraemia  may  j)r<)(lii(tc  syinplotns  very  similar  to  those  of 
tumor;  even  ehoked  disc  is  sometimes  caused,  by  nephritis. 
The  presence  of  albumin  and  casts  would  |)oint  to  unemia,  as 
would  also  the  sudden  developmejit  and  transient  nature  of 
the  symptoms  ;  of  course,  tumor  and  nephritis  may  coexist. 

Chronic  anaemia  may  simulate  tumor  even  to  the  develop- 
ment of  neuritis ;  a  history  of  long-standing  anaemia,  the 
characteristic  changes  in  the  number,  etc.,  of  the  corpuscles, 
and  the  relief  of  the  symptoms  by  appropriate  treatment 
would  distinguish  the  two. 

Symptoms  resembling  those  of  neurasthenia  and  hysteria 
may  occur  in  the  early  stages,  and  in  some  cases  prevail 
throughout  the  course  of  brain-tumor.  These  conditions  are 
especially  apt  to  be  confounded  in  growths  situated  in  the 
frontal  lobes.  Careful  investigation  will  usually  detect  the 
presence  of  organic  disease,  if  it  exists. 

Having  concluded  that  a  tumor  exists,  it  is  then  necessary 
to  decide  upon  the  location  and  variety  of  the  growth.  The 
means  of  deciding  the  former  have  been  detailed  under  focal 
symptoms.  The  latter  is  often  difficult.  The  peculiarities 
of  the  different  varieties  have  been  detailed  on  p.  270.  The 
probabilities  are  tabulated  by  Dana  as  follows  : 

Childhood Tubercle,  parasites. 

Early  life Gumma,  glioma,  parasites. 

Early  and  middle  life Sarcoma,  glioma,  gumma. 

Middle  and  late  life Sarcoma,  gumma,  cancer. 

Tumor  of  the  brain — prognosis  :  Unless  the  tumor  can  be 
removed  by  surgical  means,  the  prognosis  is  unftivorable. 
The  average  duration  of  the  symptoms  is  three  years. 

Tumor  of  the  brain — treatment :  Medical  treatment,  except- 
ing when  the  growth  is  syphilitic,  when  vigorous  antisyphilitic 
treatment  is  indicated,  is  symptomatic.  The  headache  is 
treated  by  the  measures  usually  employed  for  the  relief  of 
that  svmptom.  Vomiting  and  vertigo  may  be  relieved  by  the 
use  of  hydrobromate  of  hyosein,  gr.  yl^  every  four  hours, 
or  by  morphine  and  atropine  hypodermatically.  Convul- 
sions are  treated  by  the  usual  methods  employed  for  epilepsy. 


282  DIFFUSE  AND  LOCAL  DISEASES  OF  THE  BRAIN. 

It  is  well  in  all  cases  to  try  the  effect  of  specific  treatment. 
This  must  be  vigorous,  inunctions  of  mercury  being  em- 
ployed as  well  as  iodide  of  potassium.  The  latter  drug 
often  relieves  the  symptoms  for  a  time  of  non-syphilitic 
tumors.  If  syphilitic,  there  should  be  permanent  improve- 
ment in  the  course  of  three  months. 

Surgical  treatment,  when  the  tumor  can  be  localized  and 
reached,  should  be  resorted  to  if  specific  treatment  fails. 
Tumors  situated  in  or  near  the  cortex  are  those  suitable  for 
operation.  Fibroma  and  sarcoma  are  the  most  favorable ; 
but  glioma  and  glio-sarcoma  have  been  removed,  but  are  liable 
to  return.  About  7  per  cent,  of  tumors  are  operable.  Out 
of  fifty-five  cases  operated  upon,  analyzed  by  Ferrier  and 
Whiting,  seven  were  known  to  be  alive  one  or  more  years 
after  the  operation. 


CHAPTER    XII. 

FOCAL  AND  DIFFUSE  DISEASES  OF  THE  SPINAL  COED. 
SPINAL  LOCALIZATION. 

Reflex  and  vaso-motor  centres :  The  spinal  cord,  in  addi- 
tion to  the  carrying  of  motor  impulses  by  means  of  the 
pyramidal  tracts  from  the  brain  to  the  peripheral  nerves,  and 
of  sensory  impressions  from  the  skin,  muscles,  and  joints  to 
the  brain  (see  Motor  and  Sensory  Tracts),  contains  in  its  gray 
matter  a  number  of  cells,  some  of  which  are  the  parent-cells 
of  the  fibres  which  form  the  motor  fibres  of  the  peripheral 
nerves,  and  Avhich  also  maintain  the  nutrition  of  the  muscles 
and  act  as  reflex  centres  (Fig.  11)  and  vaso-motor  centres. 
These  are  situated  in  the  anterior  horns. 

Sensory  and  trophic  centres  :  Others,  situated  in  the  poste- 
rior horns,  receive  the  sensory  fibres  from  the  peripheral 
nerves  ;  act  as  trophic  centres  for  the  bones,  skin,  and  joints  ; 
and  (the  vesicular  column  of  Clarke,  the  axis-cylinders  of 
which  compose  the  direct  cerebellar  tract)  receive  nerve- 
fibres  from  the  viscera  and  sympathetic  system. 

Spinal  automatic  centres  :  In  the  extreme  lower  part  of  the 
cord,  situated  about  the  central  canal,  are  groups  of  cells, 
known  as  the  spinal  automatic  centers — i.  c,  the  genital,  pre- 
siding over  the  functions  of  erection  and  ejaculation ;  and 
the  bladder  and  rectal,  which  preside  over  the  functions  of 
urination  and  defecation.  They  are  controlled  as  other  re- 
flexes are  (Fig.  13). 

Segments :  The  spinal  cord  therefore  may  be  looked  upon 
as  a  series  of  thirty-one  segments  placed  one  above  the  other, 
each  of  which  is  connected  with  a  pair  of  spinal  nerves, 
contain  certain  trophic,  reflex,  and  vaso-motor  centres,  and 
through  which  run  the  motor  and  sensory  tracts  coming 
from  and  to  the  brain.     As   the  spinal   cord  only  reaches 

283 


284    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL   CORD. 


Fig.  58. 


LI.. 


■n 


M 


The  mutual  relations  of  the 
vertebral  bodies  and  spines 
to  the  segments  in  the  cord 
and  to  the  exits  of  the  nerves 
(Gowers). 


from  the  foramen  magnum  to  oppo- 
site the  base  of  the  first  lumbar  ver- 
tebra, it  can  readily  be  seen  that  all 
of  the  spinal  segments  are  not  directly 
opposite  the  vertebra  whose  name  they 
bear,  and  that  the  intraspinal  course 
of  the  nerves  after  they  emerge  from 
the  cord  is  longer  the  lower  we  de- 
scend the  cord  (Fig.  58).  Hence  the 
nerves  from  the  lumbar  and  sacral 
segments  form  a  large  bundle  (the 
Cauda  equina),  which  runs  through 
the  spinal  canal  from  their  origin  in 
the  cord  to  the  vertebra  between 
which  they  emerge.  The  eighth  cervi- 
cal and  first  dorsal  segments  lie  in 
front  of  the  spine  of  the  seventh 
vertebra.  The  lumbo-sacral  enlarge- 
ment begins  in  front  of  the  tip  of  the 
spine  of  the  tenth  dorsal  vertebra 
(Fig.  59). 

Enlargements :  The  most  important 
parts  of  the  cord  are  the  cervical  and 
the  lumbar  enlargements. 

The  former  gives  origin  to  the 
nerves  which  supply  the  arms,  and 
contains  the  cilio-spinal,  wrist-jerk, 
elbow-jerk,  scapular,  palmar,  and 
hypochondrium  reflex  centres.  The 
latter  gives  origin  to  the  nerves  which 
go  to  the  legs,  and  contains  the  reflex 
centres  for  the  plantar,  ankle-clonus, 
gluteal,  knee-jerk,  and  cremasteric 
reflexes,  and  also  the  automatic  reflex 
centres  mentioned  above. 

By  knowing  the  particular  func- 
tions of  each  spinal  segment  we 
are  enabled  to  locate  the  situation 
and  extent  of  a  focal  lesion  in  the 
cord. 


SPINAL  LOCALIZATION. 

Fig.  59. 


285 


Relations  of  the  cervical  and  lumbar  enlargements  to  the  vertebrae. 

The  following  table,  first  made  by  Starr,  and  elaborated  by- 
Mills  and  others,  shows  the  functions  of  each  segment : 


Localization  of  the   Functions  of  the  Segments  of  the  Spinal 

Cord. 


Segment. 


Second 

and 

third 

cervical. 


Fourth 
cervical. 


Muscles. 
Sterno-mastoid. 
Trapezius. 
Scaleni  and  neck. 
Diaphragm. 


L 

f  Diaphragm. 

Deltoid. 
I  Biceps, 
j  Coraco-brachialis. 

Supinator  longus. 

Rhomboid. 

Supra-  and  infraspi- 
natus. 


Seflex. 
Hy pochondri u m  (?) 
(third  to  fourth  cer- 
vical). Sudden  inspi- 
ration produced  by 
sudden  pressure  be- 
neath the  lower  bor- 
der of  ribs. 

Pupillary  (fourth  cervi- 
cal to  second  dorsal). 
Dilatation  of  the 
pupil  produced  by 
irritation  of  neck. 


Sensation. 

Back  of  neck  and  of 
head  to  vertex. 

(Occipitalis  major,  oc- 
cipitalis minor,  au- 
ricularis  magnus,  su- 
perficialis  colli,  and 
supraclavicular.) 

Neck. 

Shoulder,  anterior  sur- 
face. 

Outer  arm. 

(Supraclavicular,  c  i  r  - 
cumflex,  muscnlo-cu- 
taneous,  or  external 
cutaneous). 


286    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL   CORD. 


Segment. 


Fifth 
cervical. 


Sixth 
cervical. 


Seventh 
cervical. 


Eighth 
cervical. 


First 
dorsal. 


Second 
dorsal. 


Second 

to 
twelfth 
dorsal. 


First 
lumbar. 


Muscles. 
r  Deltoid. 

Biceps. 

Coraeo-brachialis. 

Brachialis  auticus. 

.Supinator  longus. 

Supinator  brevis. 

Deep    muscle    of 
shoulder-blade. 

Rhomboid. 

Teres  minor. 

Pectoralis    (clavicu- 
lar part). 

Serratus  magnus. 
(  Biceps. 

Brachialis  antieus. 

Subscapular. 
1  Pectoralis    (clavicu- 
J       lar  part), 
j  Serratus  magnus. 

Triceps. 

Extensors    of    wrist 
I      and  fingers. 
1^  Pronators. 

Triceps  (long  head). 

Extensors  of  wrists 
and  fingers. 

Pronators  of  wrist. 

Flexors  of  wrist. 

Subscapular. 

Pectoralis     (costal 
part). 

Serratus  magnus. 

Latissinius  dor.si. 
[  Teres  major. 
C  Triceps  (long  head). 
I  Flexors  of  wrist  and 
-i      fingers. 

I  Intrinsic  hand-mus- 
I,     cles. 

f  Extensors  of  thumb. 
I  Intrinsic  hand-mus- 
I         cles. 

-!  Thenar  and  hypothe- 
nar  muscles. 

L 


Reflex. 

Scapular  (fifth  cervical 
to  first  dorsal).  Irri- 
tation of  skin  over 
the  scapula  produces 
contraction  of  scap- 
ular muscles. 

S  a  p  I  n  a  t  o  r  loiigas 
(fourth  to  fifth  cervi- 
cal). Tapping  the 
tendon  of  the  supi- 
nator longus  pro- 
duces flexion  of  fore- 
arm. 

Triceps  (sixth  to  sev- 
enth cervical).  Tap- 
ping elbow-tendon 
produces  extension 
of  forearm. 

Posterior  wrist  (sixth  to 
eighth  cervical). 
Tapping  tendons 
causes  extension  of 
hand. 

Anterior  wrist  (seventh 
to  eiglith  cervical). 
Tapping  anterior 
tendon  causes  flex- 
ion of  hand. 

Palmar  (seventh  cervi- 
cal to  first  dorsal). 
Stroking  palm 
causes  closure  of 
fingers. 


Sensation. 

Back  of  shoulder  and 
arm. 

Outer  side  of  arm  and 
forearm  to  wrist. 

(Supraclavicular,  c  i  r  - 
cumflex,  musculo-cu- 
taneous,  or  external 
cutaneous,  internal 
cutaneous,  radial.) 


Outer  side  and  front  of 
forearm. 

Back  of  hand,  radial  dis- 
tribution. 

(Chiefly  musculo-cuta- 
ueous  or  external  cu- 
taneous, internal  cuta- 
neous.) 


f  Muscles  of  back  and 
abdomen. 
Ereetores  spinse. 


f  Ilio-psoas. 
I  Rectus. 
Sartorius. 


Epigastric  (fourth  to 
seventh  dorsal). 
Tickling  mammary 
region  causes  retrac- 
tion of  the  epigas- 
trium. 

Abdominal  (seventh  to 
eleventh  dorsal). 
Stroking  side  of  ab- 
domen causes  retrac- 
tion of  belly. 

Cremasteric  (first  to 
third  lumbar).  Strok- 
ing inner  thigh 
causes  retraction  of 
testicle. 


Radial  distribution  in 
the  hand 

Median  distribution  in 
the  palm,  thumb,  in- 
dex, and  one-half  mid- 
dle finger. 

(Musculo-cutaneous  or 
external  cutaneous, 
internal  cutaneous,  ra- 
dial, median.) 

Ulnar  area  of  hand, 
back,  and  palm,  inner 
border  of  forearm  (in- 
ternal cutaneous,  ul- 
nar). 

Chiefly  inner  side  of 
forearm  and  arm  to 
near  the  axilla. 

(Chiefly  internal  cuta- 
neous and  nerve  of 
Wrisberg  or  lesser  in- 
ternal cutaneous.) 

Inner  side  of  arm  near 

and  in  axilla. 
(Intercosto-humeral.) 

Skin  of  chest  and  abdo- 
men, in  bands  running 
around  and  down- 
ward, corresponding 
to  spinal  nerves. 

Upper  gluteal  region. 

(Intereostals  and  dorsal 
posterior  nerves.) 


Skin  over  groin  and 
front  of  scrotum. 

(Ilio-hypogastric,  ilio-in- 
guinal.) 


SPINAL  LOCALIZATION. 


287 


Segment. 

Second 
lumbar. 


Third 
lumbar. 


Fourth 
lumbar. 


Fifth 
lumbar. 


First  and 
second 
sacral. 


Third, 

fourth, 

and  iifth 

sacral. 


Muscles. 
(  Ilio-psoas. 
-;  Sartorius. 
(^  Quadriceps  femoris. 
{  Quadriceps   femoris. 

Anterior  part  of  bi- 
J      ceps. 

j  Inward    rotators    of 
i      thigh. 

t^  Abductors  of  tliigh. 
r  Abductors  of  thigh. 
I  Adductors  of  thigh. 
-i  Flexors  of  knee. 
I  Tibialis  anticus. 
L  Peroneus  longus. 
f  Outward  rotators  of 

thigh. 
I  Flexors  of  knee. 

Flexors  of  ankle. 

Peronei. 

Extensors  of  toes. 
L 

f  Flexors  of  ankle. 
I  Long  flexor  of  toes. 
■J  Intrinsic      foot-mus- 
I      cles. 
L 
r  Gluteus  maximus. 

Perineal. 
!  Muscles  of  bladder, 
rectum,  and  exter- 
nal genitals. 


Reflex. 


Patellar  (third  to  fourth 
lumbar).  Strikingpa- 
telhir  tendon  causes 
extension  (jf  leg. 


Gluteal  (fourth  to  fifth 
lumbar).  Stroking 
buttock  causes  dim- 
pling in  fold  of  but- 
tock. 

Achilles  tendon  (fifth 
lumbar  to  first  sa- 
cral). Over -exten- 
sion causes  rapid 
flexion  of  ankle, 
called  ankle-clonus. 

Plantar  (fifth  lumbar 
to  second  sacral). 
Tickling  sole  of  foot 
causes  flexion  of  toes 
and  retraction  of  leg. 

Vesical  centres. 

Anal  centres. 


L 


Fifth      ~1  Coccygeus  muscles, 
sacral      | 
and    coc-  j 
oygeal.    J 


Sensation. 

Outer  side  of  thigh. 

(Genito-crural,  external 
cutaneous.) 

Front  of  thigh. 

(Middle  cutaneous,  in- 
ternal cutaneous,  long 
saphenous,  obturator./ 


Inner  side  of  thigh,  leg, 
and  foot. 

(Internal  cutaneous, 
long  saphenous,  obtu- 
rator.) 

Back  and  outer  side  of 
leg ;  sole  ;  dorsum  of 
foot. 

(External  popliteal,  ex- 
ternal saphenous,  mus- 
culo-cutaneous,  plan- 
tar.) 

Back  and  outer  side  of 
leg;  sole;  dorsum  of 
foot. 

(Same  as  fifth  lumbar). 

Back  of  thigh,  anus, 
perineum,  external 
genitals. 

(Small  sciatic,  pudic,  in- 
ferior hemorrhoidal, 
inferior  pudendal.) 

Skin  about  the  anus  and 
coccyx. 

(Coccygeal.) 


The  areas  of  anaesthesia  caused  by  lesions  of  the  lumbo- 
sacral segments  are  shown  in  Figs.  60  and  61,  while  the  dis- 
tribution in  the  arms  due  to  cervical  lesions  of  the  segments 
is  shown  in  Fig.  62.  If  the  pathways  in  the  cord  which 
conduct  sensations  are  injured  by  the  lesion,  the  sensory  im- 
pressions received  by  the  segments  below  the  seat  of  the 
lesion  would  be  prevented  from  reaching  the  cerebrum,  and 
hence  there  would  likewise  be  ansesthesia  in  the  areas  sup- 
plied by  these  segments.  For  instance,  if  a  lesion  destroyed 
the  cord  at  the  first  lumbar  segment,  in  addition  to  the  sen- 
sory area  represented  in  that  segment,  there  M^ould  be  anaes- 
thesia in  the  areas  represented  in  all  the  segments  below  the 
first,  which  would  involve  both  legs  and  the  body  to  an  inch 
or  two  below  the  umbilicus  (Figs.  60  and  61).  On  the  other 
liand,  if  the  lesion  is  confined  to  the  nerve-roots,  the  sensory 
tracts  of  the  (!ord  escaping,  the  area  of  ansesthesia  is  confined 


288     FOCAL  AND  DIFFUSE  DISEASES   OF  SPINAL   CORD. 

to  the  area  represented  by  that  particular  segment  or  segments 
(segmental,  spinal,  or  root  type  of  anaesthesia).  This  type  is 
frequently  seen  in  tabes,  and  in  cases  of  spinal  ciaries  when 
the  nerve-roots  only,  and  not  the  cord  itself,  are  involved. 
It  has,  moreover,  been  shown  by  Sherrington  that  the  areas 
supplied  by  the  different  spinal  roots  overlap,  and  that  hence 
disease  affecting  one  root  only  would  not  cause  anaesthesia,  as 


Fig.  60. 


Fig.  61. 


VII 


Areas  of  ansesthesia  at  various  levels  of  the  spinal  cord,  from  sacral  T'to  lumbar  I ; 
7,  sacral  V;  //,  sacral  IV;  1/7,  sacral  III;  71',  sacral  I;  F,  lumbar  V ;  V7,  lum- 
bar III ;   VII,  lumbar  II  (after  Starr). 

its  area  is  supplied  from  the  next  roots  both  above  and  below. 
Therefore,  to  have  ansesthesia  of  this  type  present,  the  root 
next  above  and  that  next  below  that  segment  to  which  the 
area  of  anaesthesia  refers,  must  also  be  involved.  Anaesthesia 
due  to  peripheral  nerve  lesions  is  confined  to  the  anatomical 
distribution  of  the  nerves  in  the  skin  (see  Diseases  of  the 
Peripheral  Nerves,  j)p.  152  and  153). 

For  instance,  if  there  was  complete  paralysis  of  both  legs, 


SPINA L  LOCA LIZA  TION. 


289 


with  atrophy  of  the  flexors  and  adductors  of  the  tliigli  and 
extensors  of  the  leg,  h)ss  of  the  cremasteric  and  patellar  re- 
flexes, but  with  preservation  of  ankle-clonus  and  of  the  plantar 
reflex,  together  with  incontinence  of  urine  and  auicsthesia  in- 
volving both  legs  and  extending  upward  to  a  line  a  little  above 
the  symphysis  pubis,  we  would  know  that  there  was  a  partial 


Fig.  62. 


VIII     V      V) 
VII 

Areas  of  anaesthesia  in  lesions  of  the  cervical  cord  (Starr). 

transverse  lesion  probably  extending  from  the  first  to  the 
third  lumbar  segment.  In  such  a  case,  while  there  would  be 
complete  paralysis  of  both  legs,  atrophy  would  onlv  be  j)res- 
ent  in  the  muscles  mentioned,  because  the  cells  which  exercise 
trophic  influence  over  them  are  situated  in  the  cord  from  the 
first  to  the  third  lumbar  .segments  inclusive.  Below  the  level 
of  the  third  lumbar  segment  the  cells  are  intact  and  exercise 

J9— N.  D. 


290    FOCAL  AND  DIFFUSE  DISEASES  OF  SPfNAL   CORD. 

their  functions  ;  but  the  muscles  are  not  capable  of  voluntary 
movement,  because  impulses  from  the  brain  are  stopped  at  the 

Fig.  63. 


An  attitude  in  a  case  in  which  the  fifth  cervical  nerve  had  been  injured  on  the  left 
side  only  (Thorburn). 

lesion  ;  likewise  we  have  anaesthesia  because  sensory  impulses 
cannot  get  up.     Often  at  the  level  of  the  lesion  there  is  a 


Fig.  64. 


Peculiar  attitude  of  a  patient  in  vi^hom  the  fifth  cervical  nerves  had  not  been 
crushed  (Thorburn). 

zone  of  hyperaesthesia,  due  to  irritation  of  the  posterior  nerve- 
roots  situated  in  this  region. 

A   zone   of  anaesthesia  extending   to   the  umbilicus  corre- 
spends  to  the  eleventh  dorsal  segment ;  one  inch  above  this. 


SPINAL  LOCALIZATION. 


291 


the  tenth,  the  nipples  to  the  fourth  dorsal.  Loss  of  sensibility 
in  the  arms  is  not  present  until  the  first  dorsal  is  reached. 

A  lesion  that  damages  the  fifth  cervical  segment  and  spares 
those  below  causes  a  characteristic  group  of  symptoms.  The 
fifth  segment  supplies  chiefly  the  biceps,  brachialis  anticus, 
deltoid,  and  supinators.  Hence  if  these  muscles  are  paralyzed, 
the  elbow  will  lie  next  the  body,  and  the  forearm  and  hand 
will  lie  prone  on  the  chest  (Fig.  63).  If,  however,  the  fifth 
segment  escapes,  the  lesion  extending  even  as  high  as  the 
sixth,  the  elbow  will  be  abducted  by  the  deltoid,  the  forearm 
flexed  by  the  biceps,  the  supinators  will  supinate  the  forearm, 
and  the  infraspinatus  will  rotate  the  humerus  externally,  and 
the  patient  will  assume  the  position  shown  in  Fig.  64. 

In  complete  transverse  lesions,  those  in  which  the  cord  at 
the  seat  of  the  lesion  is  completely  destroyed,  the  deep  re- 
flexes behave  differently  from  the  way  they  do  in  partial 
lesions.  In  the  latter  those  controlled  by  centres  below  the 
seat  of  the  lesion  are  increased,  biit  in  the  former  case  they 
are  permanently  abolished.^ 


Cord. 


[  Zone  of  cutaneous  hyper- 
js,       I        sesthesia. 
C  jj   I    Zone  of  cutaneous  anaes- 
^  .2  J        thesia. 
>^  I    Paralysis   with    atrophy 
^       I        of  muscle  supplied  by 

[       the  segments  involved. 

f  Paralysis   without    atro- 
phy below  seat  of  le- 
g   I        si  on. 

^      Hypersesthesia  of  skin. 

Muscular  sense  im- 
paired. 

Reflex  action,  first  less- 
ened, then  increased. 

Temperature  raised. 


o 

pq 


Muscular  power  normal. 

Loss  of  sensibility  of  the 
skin. 

Muscular  sense  normal. 

Reflex  action  normal. 

Temperature  same  as  that 
above  the  lesion. 


'  In  acute  partial  transverse  lesions  due  to  irritation  of  the  inhibitory 
fibres,  they  may  be  temporarily  abolished,  but  return  and  usually  become  in- 
creased. 


292    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL   CORD. 

Fig.  65. 


Total  Anaesthesia. 
^ff^  Analgesia.Thermoanaesthesia. 
Hyper  aesthesia. 


PiPIII  Extreme  Hyperaesthesia  espec.  to  thermic  stimuli. 

Distribution  of  sensory  paralysis  in  heniilesion  of  the  cord  (Brown-Seqaard  paraly- 
sis) (Cashing). 


AFFECTIONS  OF  THE  BLOODVESSELS.  293 

Hemi-lesions  of  the  cord  produce  a  characteristic  group  of 
symptoms,  known  as  Brown-Sequard  paralysis.  In  typical 
cases  these  are  distributed  according  to  the  table  on  p.  291, 
slightly  modified  from  Osier's. 

The  sensory  symptoms  are  peculiar.  In  the  early  stages 
there  may  be  some  loss  of  tactile  sensibility  on  the  side  of 
the  lesion,  which  soon  disappears.  On  the  side  opposite  the 
lesion  all  forms  of  sensation,  except  muscular,  may  be  im- 
paired ;  but  as  a  rule  it  is  only  pain-  and  temperature-sense 
that  are  lost  (Fig.  65). 

AFFECTIONS  OF  THE  BLOODVESSELS. 

Embolism  and  thrombosis  occurring  in  the  spinal  arteries 
are  rare.  Hemorrhage  either  into  the  meninges  or  the  cord- 
substance  is  more  common,  the  former  being  the  more  fre- 
quent. 

Spinal  Meningeal  Hemorrhage  (Haematorrhachis). 

Etiology  :  It  occurs  in  newly  born  children  and  adults,  and 
may  be  inside  or  outside  the  dura.  The  usual  causes  in  the 
latter  are  injuries,  with  or  without  fracture  of  the  spine. 
Severe  convulsions  from  any  cause,  severe  muscular  exertion, 
purpura,  and  alterations  in  the  blood  following  infectious 
fevers,  and  the  bursting  of  an  aortic  or  vertebral  aneurism 
may  also  be  causes. 

Spinal  meningeal  -hemorrhage — symptoms  :  Small  hemor- 
rhages may  produce  no  symptoms.  In  those  large  enough  to 
cause  them  there  is  sudden  severe  pain  in  the  back,  which 
extends  into  the  limbs,  and  is  associated  with  tingling,  hyper- 
sesthesia,  and  muscular  twitchings  (irritation  of  the  nerve- 
roots).  Later,  weakness  or  paralysis  of  the  limbs,  more  or 
less  pronounced  anaesthesia  (root-type),  and  disorders  of  the 
sphincters  occur.  The  symptoms  rapidly  reach  their  height ; 
then  subside,  with  either  recovery  gradually  occurring  or 
symptoms  of  chronic  meningitis  remaining.  More  rarely  the 
blood  gravitates  to  the  end  of  the  cord,  causing,  as  the  blood 
gradually  fills  up  the  vertebral  cavity,  symptoms  of  an  as- 
cending paralysis. 


294    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL  CORD. 

Diagnosis :  The  diagnosis  is  based  upon  the  sudden  onset 
of  the  symptoms  following  injury  or  other  of  the  causes 
mentioned ;  the  presence  of  severe  pain  and  nerve-root  irri- 
tation, and  the  subsidence  of  the  symptoms. 

In  hemorrhage  into  the  cord-substance  there  are  less  pain  and 
irritation,  and  more  pronounced  and  permanent  motor  and 
sensory  paralysis.  When  the  cord  is  crushed,  due  to  disloca- 
tion or  fracture,  the  symptoms  more  resemble  those  of  hsema- 
tomyelia,  and  external  evidences  of  the  injury  can  usually  be 
found. 

The  prognosis  is  grave ;  but  if  death  does  not  occur  in  a 
few  days,  the  prospect  of  partial  or  nearly  complete  recovery 
is  good. 

Spinal  meningeal  hemorrhage — ^treatment :  This  consists  of 
absolute  rest,  cold  to  the  spine,  and  the  administration  of 
remedies  to  relieve  pain  and  move  the  bowels.  For  the  later 
symptoms  iodide  of  potassium,  mercury,  and  counterirritation 
to  the  spine  may  be  employed.  In  cases  associated  with 
fracture  or  dislocation  surgical  measures  may  be  indicated. 

Hemorrhage  into  the  Substance  of  the  Cord 
(Hsematomyelia). 

Etiology :  Injuries,  overexertion,  excessive  sexual  inter- 
course, exposure,  syphilitic  or  other  disease  of  the  blood- 
vessels, purpura,  and  convulsions  are  causes.  It  may  occur 
secondarily  in  myelitis  and  spinal  tumor.  It  sometimes 
occurs  in  infancy,  but  is  most  common  between  the  ages  of 
twenty  and  forty. 

Hsematomyelia — symptoms  :  These  appear  suddenly  ;  a  feel- 
ing of  numbness  and  weakness  in  the  extremities  being  first 
noticed,  which  in  an  hour  or  so  develops  into  complete  para- 
plegia, with  anaesthesia  and  paralysis  of  the  sphincters.  The 
reflexes  are  at  first  absent,  but  soon  reappear  and  become 
exaggerated.  There  may  be  some  pain  in  the  back.  The 
location  of  the  hemorrhage  can  be  determined  by  the  methods 
detailed  under  Spinal  Localization.  Symptoms  of  acute  mye- 
litis may  soon  appear  and  death  result.  Or  they  may  sub- 
side in  the  course  of  a  week  or  so,  leaving  a  permanent  con- 
dition similar  to  chronic  myelitis. 


AFFECTIONS  OF  THE  BLOODVESSELS.  295 

Morbid  anatomy :  The  lower  cervical  region  is  the  most 
common  seat  of  the  hemorrhage,  which  is  chiefly  in  the  gray- 
matter.  The  clot  may  be  absorbed,  leaving  a  cavity,  which 
may  cause  the  symptoms  of  syringomyelia.  While  the 
hemorrhage  is  commonly  single,  multiple  hemorrhages  may 
occur. 

The  diagnosis  is  based  upon  the  sudden  onset,  without  pro- 
dromes, and  absence  of  fever.  The  features  which  distin- 
guish it  from  spinal  hemorrhage  have  been  mentioned  under 
that  condition.  It  may  be  mistaken  for  acute  myelitis,  which 
is  often  produced  by  it,  and  is  sometimes  its  cause. 

The  prognosis  is  serious ;  death  often  occurs,  and  perma- 
nent disability  of  more  or  less  extent  is  always  the  result. 
Hemorrhages  below  the  cervical  region  are  the  most  favor- 
able. 

Hsematomyelia — treatment :  Absolute  rest ;  ice-bags  to  the 
spine,  and  remedies  to  lessen  the  heart's  action.  Treatment 
after  the  acute  attack  is  the  same  as  that  employed  in  myelitis. 

Caisson  Disease  (Divers'  Paralysis). 

Definition — etiology :  By  this  we  mean  a  more  or  less  com- 
plete paraplegia  which  occurs  in  persons  who  suddenly  re- 
turn from  a  condensed  air  to  the  normal  atmosphere. 

It  occurs  in  those  who  work  in  caissons  when  the  pressure 
is  over  one  atmosphere.  It  rarely  occurs  when  the  pressure 
is  not  over  that ;  and,  also,  if  the  person  has  not  been  sub- 
jected to  the  pressure  for  at  least  an  hour.  Alcoholism,  old 
age,  and  obesity  are  predisposing  causes. 

Caisson  disease — symptoms :  Soon  after  the  patient  has 
come  out  of  the  caisson  he  is  seized  with  pains  in  the  legs 
and  epigastrium.  These  are  succeeded  by  nausea,  vomiting, 
and  weakness  of  the  limbs.  There  may  also  be  headache 
and  in  some  cases  coma.  Complete  paralysis,  with  anaes- 
thesia ;  disturbances  of  the  sphincters,  and  severe  shooting 
pains  may  develop. 

Morbid  anatomy — pathology :  Congestion  and  softening  of 
the  cord  are  found.  Microscopically,  destruction  of  the 
nerve-tissue  of  the  posterior  and  lateral  columns  in  the  dor- 
sal region  was  found  in  four  cases.     The  pathology  of  these 


296    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL   CORD. 

changes  is  obscure.  The  pressure  probably  causes  overclis- 
tention  of  bloodvessels  by  paralysis  of  their  wails.  When 
the  pressure  is  removed  they  are  unable  to  accommodate 
themselves  to  the  changed  conditions,  and  stasis  and  conges- 
tion result. 

Caisson  disease — prognosis — treatment :  Most  cases  recover ; 
but  either  death  may  occur  or  a  permanent  weakness  or 
paralysis  result. 

Treatment  consists  of  rest,  use  of  morphine  for  pain,  and, 
if  paralysis  results,  measures  similar  to  those  employed  in 
myelitis. 

INFLAMMATION  OF  THE  SPINAL  CORD  (MYELITIS). 

This  may  be  acute,  subacute,  or  chronic.  If  the  gray 
matter  only  is  affected,  it  is  termed  poliomijelitk  (see  p.  208) ; 
if  a  small  vertical  extent  of  both  gray  and  white  matter, 
transverse  myelitis ;  if  an  extensive  area  of  both  white  and 
gray  matter,  diffuse  myelitis ;  if  a  considerable  area  of  gray 
matter,  central  myelitis;  if  in  scattered  areas,  disseminated 
myelitis.  According  to  the  cause,  we  have  hemorrhagic  mye- 
litis when  due  to  hemorrhage  ;  compression  myelitis  when  due 
to  vertebral  disease  or  tumor ;  and  tubercular  and  syphilitic 
myelitis. 

Acute  Myelitis. 

Etiology :  Most  cases  occur  between  the  ages  of  ten  and 
forty  years.  The  causes  are  injuries  causing  laceration  or 
bruising  of  the  cord  ;  or  hemorrhage  within  its  substance. 
There  may  be  either  fracture  or  dislocation  of  the  vertebrae,  or 
violent  blows  or  falls  upon  the  back  without  apparent  bone 
injury  ;  hemorrhage  occurring  independently  of  trauma  ;  ex- 
tension of  inflammation  from  neighboring  organs ;  spinal  men- 
ino:itis,  the  inflammation  extendino;  from  the  membranes  to 
the  cord;  exposure  to  cold  and  wet;  toxic  agents — /'.  e.,  in- 
fectious diseases,  .syphilis,  and  more  rarely  the  metallic  poisons. 
When  due  to  metallic  poisoning,  multiple  neuritis  usually  co- 
exists.    In  many  cases  no  cause  can  positively  be  determined. 

Acute  myelitis — morbid  anatomy :  This  presents  three 
stages.     In  the  first  the  membranes  of  the  cord  are  usually 


INFLAMMATION  OF  THF  SPINAL  CORD.  297 

more  or  loss  opaque.  The  substance  of  the  cord  is  softer 
than  normal,  and  may  he  either  swollen  or  shrunken.  Upon 
section  the  surface  is  pink,  and  there  may  be  minute  hemor- 
rhages (red  softening).  Mirroticopicnlly,  there  is  great  con- 
gestion of  the  bloodvessels,  more  marked  in  the  veins ;  a 
considerable  amount  of  perivascular  cellular  exudate,  the 
majority  of  the  cells  being  polynuclear  leukocytes.  The 
myelin-sheaths  show  evidences  of  degeneration  ;  the  axis- 
cylinders  are  swollen  and  granular,  the  neuroglia-cells  are 
sometimes  sAvollen  and  increased  in  number,  and  the  neu- 
rogliar  tissue  is  looser  than  normal.  The  ganglion-cells  also 
show  evidences  of  degeneration.  If  the  process  has  lasted 
any  time,  there  is  considerable  accumulation  of  granular  cells. 

In  the  next  stage  section  of  the  cord  shows  the  color  to  be 
yellow  (yellow  softening).  The  bloodvessels  are  shrunken  ; 
the  cellular  exudate  is  still  present,  but  the  cells  show  evi- 
dences of  fatty  degeneration.  Compound  granular  cells  are 
abundant.  The  nerve-fibres  and  ganglion-cells  are  degener- 
ated. If  a  severe  case,  the  substance  of  the  cord  may  con- 
sist of  a  puriform  mass  consisting  of  fat-globules,  granular 
cells,  and  detritus. 

In  the  third  stage,  that  of  gray  degeneration,  there  is 
secondary  distention  of  the  bloodvessels,  causing  the  cord  to 
assume  a  redder  apj)earance  than  is  found  in  the  previous 
stage;  and  proliferation  of  connective  tissue.  Granular  cells 
are  principally  found  in  the  neighborhood  of  the  bloodvessels. 
The  nerve-fibres  and  ganglion-cells  have  mostly  disappeared, 
and  secondary  degenerations  are  found  above  and  below  the 
seat  of  the  lesion. 

Acute  myelitis — symptoms  :  The  most  common  type  is  aeute 
transverse  myelitis.  The  first  symptom  noticed  is  a  feeling  of 
numbness  in  the  feet  and  legs.  Weakness  soon  develops, 
and  in  the  course  of  a  day  or  so,  sooner  in  some  cases,  a  com- 
plete bilateral  paralysis  of  motion  and  sensation  has  de- 
veloped. The  location  of  the  paralysis  depends  upon  the 
location  of  the  lesion,  determined  by  the  methods  detailed 
under  Spinal  Localization.  The  usual  location  is  the  dorsal 
or  lumbar  region,  when  a  paralysis  of  both  legs  results. 
Either  retention  or  incontinence  of  urine  is  also  an  early 
symptom.     There  may  be  some  fever. 


298    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL  CORD. 

After  the  symptoms  have  fully  developed  there  will  be 
found  more  or  less  complete  paralysis  of  the  legs,  anaesthesia 
to  touch,  pain,  and  temperature  in  various  degrees  extending 
up  to  nearly  the  lowest  limit  of  the  lesion.^  If  the  anaes- 
thesia is  not  complete  for  all  forms,  it  is  usually  greatest  to 
touch,  next  to  temperature.  At  the  level  of  the  upper  limit 
of  anaesthesia  there  is  a  feeling  as  if  a  tight  band  were 
about  the  body  (girdle-pain),  above  which  there  is  often  a 
zone  of  hyperaesthesia.  The  legs  feel  numb  and  heavy,  but 
there  is  no  other  pain  nor  tenderness.  The  sphincters  of  the 
bladder  and  bowels  are  affected  according  to  the  location 
of  the  lesion.  The  bladder  is  anaesthetic,  and  the  urine  re- 
tained. In  time,  if  it  is  not  drawn,  an  incontinence  from 
overflow  will  develop.  The  rectum  is  also  anaesthetic  and 
the  bowels  constipated ;  when  they  do  move  the  patient  is 
unaware  of  it.  In  lumbar  lesions  sexual  power  is  abolished  ; 
in  those  situated  above  this  region  priapism  may  occur.  The 
legs  after  a  few  days  feel  cold.  Bedsores,  oftenest  upon  the 
buttocks  and  heels,  develop  early.  Muscles  whose  nerve- 
supply  originates  in  the  diseased  area  atrophy,  exhibit  reac- 
tions of  degeneration,  and  the  reflexes  of  that  region  are  ab- 
sent. Those  below  the  seat  of  lesion  become  spastic,  and 
contractures  develop  and  the  reflexes  are  increased^  (see 
Spinal  Localization). 

When  the  cervical  region  is  attacked  the  arms  are  also 
paralyzed  ;  unequal  or  dilated  pupils  from  involvement  of 
the  cilio-spinal  centre  and  sometimes  optic  neuritis  occur. 

If  the  patient  lives  a  few  weeks,  some  improvement  sets 
in.  Sensation  first  begins  to  return,  then  motion  ;  so  that,  in 
from  a  few  months  to  a  year,  walking  again  becomes  possible  ; 
but  as  secondary  degeneration  in  the  motor  and  sensory 
tracts  has  occurred,  the  patient  is  left  with  symptoms  resem- 
bling those  of  ataxic  paraplegia. 

The  myelitis  may,  from  the  original  focus,  extend  either 
up  or  down  the  cord  (diffuse  myelitis),  causing  a  progression 

^  The  nerves  emerge  at  a  lower  level  than  their  origin  in  the  cord  (see 
Segments  of  Cord,  p.  283). 

"  As  iias  i)een  before  stated,  in  lesions  which  completely  divide  the  cord 
the  deep  reflexes  are  lost. 


INFLAMMATION  OF  THE  SPINAL   CORD. 


299 


of  the  symptoms  accordingly.     If  it  extends   up,  Landry's 
disease  is  simulated. 

The  accompanying  table   shows   the  principal  symptoms 
present  in  lumbar,  dorsal,  and  cervical  myelitis  (Prince)  : 


Lumbar  myelitis. 

Dorsal  myelitis. 

Cervical  myelitis. 

Paralysis. 

Paraplegia. 

1.  Dorsal,    abdominal, 
and  intercostal  mus- 
cles    according     to 
height  of  lesion.    2. 
Legs. 

Neck  muscles,  dia- 
phragm, arms, 
trunk,  and  legs. 

Sensation. 

Pains  in  legs,  or  girdle- 
pains  around    loins ; 
hypersesthetic      zone 
around  loins ;  anaes- 
thesia of  legs,  com- 
plete or  uneven  dis- 
tribution. 

Girdle-pain  and  hyper- 
sesthetic    zone     be- 
tween ensiform  car- 
tilage and  pubes. 

Hyperaesthesia  and 
pains  in  certain 
nerve  -  distribu- 
tions of  arms ;  be- 
low this,  anaesthe- 
sia of  arms,  body, 
and  legs. 

Atrophy. 

Of  legs. 

Of  dorsal  and  abdomi- 
nal (and  intercostal 
muscles,  not  subject 
to  examination)  cor- 
responding to  height 
of  lesion ;  sometimes 
mild    and    slow   of 
legs. 

Atrophy  of  neck 
muscles  (rare)  or 
more  commonly 
of  arms. 

Electrical 
reaction. 

DeR  in  atrophied  mus- 
cles ;  or  in  mild  cases 
quantitative  diminu- 
tion. 

DeR  in  dorsal  and  ab- 
dominal     muscles; 
slight     quantitative 
changes  only  in  legs 
when  wasted. 

DeR  in  atrophied 
muscles. 

Bladder. 

Incontinence  from  pa- 
ralysis of  sphincter. 

Retention,    or    inter- 
mittent incontinence 
from  reflex  actions ; 
later  from  overflow. 
Cystitis  common. 

Same  as  in  dorsal 
myelitis. 

Bowels. 

Incontinence  from  pa- 
ralysis of    sphincter, 
disguised   by  consti- 
pation. 

Involuntary     evacua- 
tion     from      reflex 
spasm,  or  constipa- 
tion. 

Same  as  in  dorsal 
myelitis. 

Reflexes, 
superficial. 

Lost. 

Temporary  loss,  then 
rapid  increase. 

Same  as  in  dorsal 
myelitis. 

Reflexes, 

deep. 

Lost. 

Temporary  loss,  then 
slow  increase. 

Same  as  in  dorsal 
myelitis. 

Priapism. 

Absent. 

Often  present. 

Often  present. 

Acute  myelitis — diagnosis  :  Difficulty  should  only  occur  in 
mild  or  partial  cases.  The  diseases  with  which  it  may  be 
confounded  are  central  myelitis,  poliomyelitis,  disseminated 
myelitis,  hemorrhage,  embolic  or  thrombotic  softening,  mul- 
tiple neuritis,  lesions  of  the  cauda  equina,  Landry's  disease, 
spinal   meningitis,   and   hysterical   paralysis.     From   central 


300    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL  CORD. 

myelitis  the  diagnosis  is  difficult.  These  cases  are  very  ma- 
lignant ;  and  as  the  symptoms  are  due  to  an  inflammation  of 
the  gray  matter  which  extends  up  and  down  the  cord  for  a 
considerable  distance,  they  are  diffuse  ;  there  being  consider- 
able fever,  and,  owing  to  the  extensive  damage  to  the  trophic 
centres  of  the  muscles,  widespread  atrophy.  If,  as  rarely 
occurs,  the  central  myelitis  is  focal,  atrophy  is  limited  to  cer- 
tain groups  of  muscles,  and  dissociation  of  sensation  may  be 
present.  These  cases  resemble  syringomyelia,  and  are  usually 
due  to  trauma. 

In  jjoliovii/elitw  sensation  is  not  affected,  and  there  is  no 
involvement  of  the  sphincters ;  bedsores  and  girdle-pain  do 
not  occur.  The  onset  of  hemorrhage  is  usually  more  sudden 
than  that  of  myelitis.  The  fact  that  myelitis  may  occur 
secondarily  to  hemorrhage  must  be  borne  in  mind. 

In  disseminated  layelifix  the  symptoms  are  scattered,  and 
appear  as  ]>aralyses  of  sej)arated  groups  of  muscles  and 
patches  of  anaesthesia  irregularly  distributed. 

Multiple  nevrifis  differs  in  the  absence  of  sphincter  involve- 
ment, girdle-pain,  bedsores,  extensive  area  of  anaesthesia,  and 
the  less  rapid  development  of  the  paralysis  ;  while  pain  and 
tenderness  over  the  nerve-trunks  are  present. 

Lesions  of  the  canda  equina  are  usually  characterized  by 
asymmetry  of  the  motor  and  sensory  loss ;  the  sphincters  are 
not  apt  to  be  severely  involved.  Pain  in  the  area  of  anaes- 
thesia, as  distinguished  from  pain  above  it  (girdle-pain),  points 
to  lesion  of  the  cnuda. 

In  Lavdrifs  paralysis  there  is  absence  of  sensory  disturb- 
ances, sphincter  paralysis,  muscular  wasting,  and  atrophy. 

In  meningitis,  hypersesthesia,  pain,  and  muscular  spasms  are 
present ;  paralysis  is  not  so  marked,  the  sphincters  escape, 
bedsores  do  not  occur.  Hysterical  paraplegia  is  distinguished 
by  the  absence  of  atrophy,  trophic  changes,  and  the  presence 
of  hysterical  stigmata. 

Acute  myelitis — prognosis  :  Tlie  prognosis  is  serious.  Pa- 
tients who  do  not  die,  rarely  recover  full  power.  Myelitis 
involving  the  cervical  region  is  most  dangerous  to  life.  High 
temperature  is  a  bad  sign.  The  milder  the  degree  of  paral- 
ysis the  better  the  prognosis  as  regards  recovery  of  function. 
Hope  of  such  result  should  not  be  lost  until  at  least  a  year 


INFLAMMATION  OF  THE  SPINAL   COBD.  301 

has  elapsed.     Patients  may  remain  bedfast  for  a  year  or  more, 
and  finally  die  of  exiianstion  due  to  bedsores  and  cystitis. 

Acute  myelitis — treatment:  For  the  attack,  rest  in  bed — a 
water-bed,  if  possible ;  leeches  or  wet  cups  applied  to  the 
spine  ;  a  calomel  purge ;  dia])horesis  and  small  doses  of  aco- 
nite are  indicated.  The  bladder  should  be  carefully  watched  ; 
the  urine  drawn  at  intervals,  and  frequently  examined.  If 
cystitis  develops,  appropriate  treatment  must  be  instituted. 
After  a  week  small  doses  of  iodide  of  potassium  may  be 
given.  After  a  month,  if  fever  has  subsided,  strychnine  and 
the  use  of  electricity  should  be  cautiously  begun.  Bedsores 
must  be  guarded  against,  and  if  they  appear  must  be  treated 
by  the  usual  surgical  methods.  Warm  baths  may  help  the 
contractures.  As  syphilis  is  a  frequent  cause,  a  course  of 
antisyphilitic  treatment  in  the  early  stages  is  advisable. 

Chronic  Myelitis. 

Etiology :  It  may  be  the  sequel  of  a  previous  acute  myelitis 
or  be  due  to  extension  from  a  meningitis  ;  or  it  may  be  caused 
primarily  by  syphilis,  exposure  to  cold,  alcoholism,  infectious 
diseases,  falls,  or  blows  upon  the  spine. 

Morbid  anatomy :  The  nervous  tissues  degenerate  or  have 
degenerated  as  described  under  acute  myelitis,  while  the  neu- 
roglia and  connective  tissue  greatly  increases  in  amount.  The 
bloodvessels  become  thickened  and  their  lumen  diminishes. 
Secondary  degenerations  are  found.  The  pia  may  be  thick- 
ened and  adherent  to  the  cord.  To  the  naked  eye  the  cord  is 
shrunken  and  harder  than  normal,  and  the  cut  surface  is 
grayish  in  color. 

Chronic  myelitis — symptoms :  These  develop  much  slower 
than  do  those  of  acute  myelitis,  but  when  fully  developed 
are  essentially  the  same.  Years  may  elapse  before  this  takes 
place.  The  patient  at  first  complains  of  numbness  of  the 
legs  and  notices  that  he  tires  easily ;  from  that  weakness 
gradually  progresses,  but  it  may  be  years  before  he  is  ren- 
dered helpless.  Sensory  disturbances  also  appear :  there 
may  be  some  but  not  severe  pain,  tinglings  and  numbness  of 
the  legs,  and  anaesthesia,  which  is  usually  not  so  pronounced 
as  in  the  acute  form.     As  the  gray  matter  is  involved,  there 


302    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL   CORD. 

is  atrophy,  with  reactions  of  degeneration  in  the  muscles 
supplied  by  the  diseased  segments.  Disturbances,  varying 
according  to  the  location  of  the  lesion,  of  the  sphincters  de- 
velop, inability  to  hold  the  urine  being  the  most  common. 
Before  the  entire  thickness  of  the  cord  is  involved  the  symp- 
toms resemble,  according  to  the  part  of  the  cord  then  aifected, 
some  of  the  system  diseases.  For  instance,  the  gait  may  be 
ataxic  when  the  posterior  columns  are  damaged  ;  when  the 
lateral  columns  are  principally  affected  the  symptoms  re- 
semble those  of  lateral  sclerosis  ;  if  both  lateral  and  posterior 
columns  suffer,  ataxic  paraplegia  is  simulated.  After  the 
entire  thickness  of  the  cord  is  involved  the  symptoms — 
motor,  sensory,  trophic,  etc. — resemble  those  of  the  acute 
form.  These,  as  regards  the  condition  of  the  reflexes,  dis- 
tribution of  atrophy,  rigidity  or  flaccid ity  of  the  muscles,  of 
course  depend  upon  the  location  of  the  lesion,  which  is  deter- 
mined by  the  methods  laid  down  in  the  chapter  on  Spinal 
Localization. 

In  disseminated  myelitis,  as  the  foci  are  scattered  through- 
out the  cord,  all  possible  combinations  may  be  present. 

Chronic  myelitis — diagnosis  :  Lateral  sclerosis,  compression- 
myelitis,  and  progressive  muscular  atrophy,  amyotrophic 
lateral  sclerosis,  ataxic  paraplegia,  chronic  meningitis,  may 
be  mistaken  for  chronic  myelitis.  The  existence  of  sensory 
symptoms  and  atrophy  distinguish  it  from  the  former. 

The  atrophy  in  progressive  muscular  atrophy  usually  be- 
gins in  the  hand  or  shoulder  muscles,  and  there  are  no  sen- 
sory symptoms  or  involvement  of  the  sphincters. 

Amyotrophic  lateral  sclerosis  would  be  distinguished  by  the 
absence  of  sensory  symptoms  and  paresis  of  the  sphincters. 

In  ataxic  paraplegia  there  is  no  ansesthesia  or  muscular 
atrophy  present. 

Meningitis  is  characterized  by  the  greater  amount  of  pain, 
muscular  twitchings,  hypersesthesia,  etc.,  which  are  present. 
Meningitis  and  myelitis  often  occur  together. 

The  symptoms  of  compression-myelitis  are  described  on 
p.  303. 

Prognosis :  The  course  of  the  disease  usually  extends  over 
years.  It  may  cease  to  progress  and  remain  stationary, 
which  may  be  either  permanent  or  followed  later  by  an  in- 


INFLAMMATION  OF  THE  SPINAL   COED.  303 

crease  of  symptoms.  All  that  we  can  hope  to  do  by  treat- 
ment is  to  arrest  the  progress  of  the  disease.  Slight  im- 
provement in  the  symptoms  already  present  may  occur  if  all 
of  the  nervous  elements  are  not  completely  destroyed.  Death 
may  finally  occur  from  exhaustion  due  to  the  development  of 
bedsores  and  cystitis,  or  from  some  intercurrent  disease. 

Chronic  myelitis — treatment :  The  patient  must  be  cautioned 
against  overexertion  and  physical  fatigue.  If  possible,  he 
should  live  in  a  warm  equable  climate.  If  this  cannot 
be  done,  exposure  to  inclement  weather  should  be  avoided. 
Daily  warm  baths  are  often  beneficial. 

It  is  well  in  all  cases  to  try  antisyphilitic  treatment.  If 
this  fails,  drugs  can  only  do  good  as  tonics,  and  such,  espe- 
cially arsenic  and  silver  nitrate,  should  be  employed.  If 
there  is  much  muscular  rigidity,  strychnine  should  be  avoided. 

Counterirritation  to  the  spine  by  means  of  blisters  or  cau- 
tery may  be  tried.  Electricity  may  be  employed  to  relieve  pain 
if  it  is  present.  A  faradic  brush  current  of  moderate  strength 
brushed  over  the  painful  areas  daily  is  often  of  service. 

The  occurrence  of  cystitis  and  bedsores  must  be  guarded 
against,  and  if  they  occur  treated  by  the  usual  methods. 

The  nutrition  of  the  muscles  may  be  kept  up  by  electricity 
and  massage. 

Compression  of  the  Spinal  Cord  (Compression- 
myelitis)  . 

Etiology :  This  is  an  interruption  of  the  functions  of  the 
cord  due  to  slow  and  continuous  pressure.  It  may  occur  at 
any  age.  It  is  caused  by  caries  of  the  vertebra,  either  tuber- 
cular or  syphilitic,  usually  the  former ;  new  growths  spring- 
ing from  the  bone  or  membranes  ;  aneurism  of  the  abdominal 
or  thoracic  aorta,  and  the  development  of  the  echinococcus 
cyst  in  the  vertebral  canal. 

Compression-myelitis — symptoms :  The  onset  of  the  symp- 
toms is  slow,  and  characterized  at  first  by  the  development  of 
symptoms  indicating  irritation  of  the  nerve-roots,  as  shoot- 
ing-pains in  the  course  of  the  nerve-trunks  and  muscular 
twitchings.  Symptoms  similar  to  those  of  chronic  myelitis 
then  develop. 


304    FOCAL   AND  DIFFUSE  DISEASES   OF  SPINAL   CORD. 

If  due  to  vertebral  caries,  kyphosis  can  usually  be  de- 
tected :  there  would  be  teuderness  over  the  diseased  vertebra 
and  great  pain  produced  by  movements  or  jarring  of  the 
spinal  column. 

Morbid  anatomy  :  Meningitis  is  often  associated  (see  p.  189). 
The  cord  may  appear  anaemic  and  thinner  than  normal  at 
the  point  of  pressure ;  and  if  the  process  has  been  long- 
continued  is  much  firmer.  3IiGroscopically ,  various  stages  of 
degeneration  of  the  nerve-elements  at  the  point  of  pressure 
and  secondary  degenerations  in  the  different  tracts  are 
found. 

Diagnosis :  The  association  of  the  symptoms  with  any  of 
the  causes  given  determines  the  diagnosis. 

The  prognosis  is  fair.  In  the  cases  due  to  vertebral  caries, 
these,  if  recognized  early  and  subjected  to  proper  treatment, 
often  recover  a  considerable  amount  of  function.  Cases  due 
to  either  aneurism  or  tumor  are,  of  course,  hopeless. 

The  treatment  of  cases  due  to  caries  consists  of  rest  In 
bed,  with  extension,  and  the  various  other  mechanical  meth- 
ods employed  by  surgeons  for  the  treatment  of  spinal  caries. 

If  due  to  syphilis,  antisyphilitic  treatment  should  be  em- 
ployed in  addition. 

In  the  tubercular  cases  cod-liver  oil  and  other  tonics,  good 
food,  fresli  air,  etc.,  are  indicated.  If  this  treatment  has 
been  employed  for  a  year  without  improvement,  the  perform- 
ance of  a  laminectomi/  may  be  considered. 

LESIONS  OF  THE  CONUS  MEDULLARIS  AND  CAUDA 
EQUINA. 

These  may  be  caused  by  injury,  tumor,  or  caries  below  the 
first  lumbar  vertebra. 

A  lesion  of  the  conus  is  indicated  by  paralysis  of  the 
bladder  and  rectum,  the  spinal  centers  for  Avhich  are  there 
situated,  without  the  presence  of  motor  or  sensory  symptoms. 

If  the  lesion  is  not  limited  strictly  to  the  conus,  a  small 
area  of  aneesthesia  involving  the  perineum  and  surrounding 
the  anus  is  present.    It  is  indicated  in  that  marked  /,  Fig.  61. 

Lesions  involving  the  cauda  equina  are  difficult  to  distin- 
guish  from   those   affecting   the   cord   segments   which    give 


TUMORS  OF  THE  SPINAL   CORD.  305 

origin  to  the  nerve  composing  it.  A  lack  of  symmetry  on 
the  two  sides  in  the  distribution  of  the  motor  and  sensory 
paralysis  ;  a  slow  and  irregular  development  of  the  symp- 
toms ;  the  greater  involvement  of  the  nerves  from  the  lower 
segments  (sacral  segments),  and  widespread  motor,  with  slight 
sensory  paralysis,  point  to  lesions  of  the  cauda.  The  reflexes 
may  be  absent,  diminished,  or  normal  according  to  the  nerves 
involved  ;  but  they  are  never  exaggerated.  Pain  and  tender- 
ness in  the  sacral  region  may  be  noted.  Of  course,  if  a  fract- 
ure or  dislocation  exists  below  the  first  lumbar  vertebra,  the 
diagnosis  is  easy. 

The  diagnosis  from  neuritis  of  the  lumbar  and  sacral  plex- 
uses has  been  discussed  on  p.  164. 

The  treatment  consists  of  the  removal  of  the  cause,  if 
possible,  and  the  promotion  of  the  nutrition  of  the  muscles 
by  tonics,  massage,  and  electricity. 

TUMORS  OF  THE  SPINAL  CORD. 

Etiology  :  With  the  exception  of  syphilitic,  tubercular,  par- 
asitic, and  some  cystic  formations,  we  do  not  know  the  cause 
of  the  formation  of  tumors.  Cystic  growths  may  sometimes 
be  the  result  of  a  previous  hemorrhage  due  to  traumatism. 
Malignant  growths  may  be  secondary  to  similar  growths  else- 
where in  the  body. 

Situation:  Tumors  may  develop  within  the  cord  itself; 
spring  from  any  of  its  membranes  or  from  the  tissues  outside 
the  dura,  as  the  fat  lying  between  the  dura  and  vertebra ;  the 
vertebrae  themselves  or  the  intervertebral  cartilages.  For 
clinical  purposes  they  may  be  conveniently  classified  into  (1) 
medullary  or  tumors  of  the  cord  ;  (2)  extra-medullary  or  tu- 
mors of  any  of  the  envelopes. 

Tumors  of  the  first  variety  are  much  more  rare  than  those 
of  the  second.  In  130  cases  there  were  97  which  originated 
outside  the  cord,  49  of  which  were  between  the  dura  and  the 
cord,  and  19  which  developed  within  the  cord,  with  14  whose 
location  was  doubtful. 

The  variety  of  tumors  met  with  and  their  relative  fre- 
quency are  indicated  in  the  following  table  ; 

20— N.  D, 


306    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL   CORD. 

Sarcoma  (different  varieties) 36 

Myxoma 15 

Tubercle 15  > 

Echinococcus     10 

Fibroma 8 

Gumma 8 

Lipoma 7 

Glioma 6 

Psammoma 5 

Neuroma 2 

Osteoma 2 

Phlegmon 1 

Aneurism 1 

Dermoid  Cyst 1 

Blood-clot      1 

Angeio-fibroma 1 

Lymphangeioma 1 

Fibro-cliondro-lipoma 1 

Undetermined 4 

130 

Glioma  is  always  met  with  within  the  cord,  usually  about 
the  central  canal,  and  frequently  gives  rise  to  the  symptoms 
of  syringomyelia  (see  p.  3()9), 

Tumors  are  usually  single,  but  may  be  multiple. 

Morbid  anatomy :  Tumors  developed  outside  the  cord  com- 
press its  substance,  producing  a  compression-myelitis  (see  p, 
303).  The  membranes  in  the  neighborhood  of  the  growth 
may  be  cedematous  and  congested. 

In  tumors  of  the  cord-substance  the  cord  is  enlarged  at  the 
seat  of  the  growth,  and  on  section  the  structures  of  the  cord 
will  be  observed  to  be  pressed  out  of  their  normal  posi- 
tion (Fig.  66).  The  tumor  will  be  firmer  than  the  surround- 
ing cord-substance,  which  will  be  softer  than  normal.  Cavi- 
ties are  frequently  formed  in  gliomatous  growths  (see  Syrin- 
gomyelia). Secondary  degenerations  occur  in  the  tracts  de- 
stroyed or  pressed  upon  by  the  growth. 

Tumors  of  the  spinal  cord — symptoms :  Pain  is  usually  the 
first  symptom  noted.  This  is  due  to  irritation  of  the  poste- 
rior nerve-roots,  which  produces  sharp,  shooting  pains  in  the 
course  of  the  peripheral  nerves  affected  ;  and  to  irritation  of 
the  sensory  tracts  of  the  cord  which  causes  diffused  pain, 
often  occurring  in  anaesthetic  areas.  In  tumors  situated  on 
the  anterior  surface  of  the  cord,  marked  pain  may  be  absent. 


TUMORS  OF  THE  SPINAL   CORD. 


307 


The  anterior  nerve-roots  may  be  also  irritated,  producing 
muscular  spasms  and  rigidity.  As  the  different  parts  of  the 
cord  are  either  compressed  or  destroyed  symptoms  similar  to 
those  of  myelitis  develop.  These  may  be  those  of  acute 
myelitis,  but  more  commonly  are  those  of  compression-mye- 


FiG.  66. 


,iX^' 


^, 


'\ 


Gliosarcoma  of  the  cord.    Nigrosin  stain.    (From  specimen  kindly  furnished  by 
E.  W.  Taylor.) 


Wlien  limited  to  one  lateral  half  of  the 
resembling;    the    Brown-Sequard    syndrome 


litis  (see  p.  303). 
cord    symptoms 

develop,  which,  as  the  tumor  grows,  develop  into  a  complete 
paraplegia.  According  to  Starr,  the  order  in  which  the  symp- 
toms arise  is  commonly  :  (1)  peculiar  pains  of  limited  distri- 
bution ;  (2)  iiua-case  of  reflexes  bellow  the  lesion  ;  (3)  para- 
ph'gia;  (4)  h>ss  of  sensibility  ;  (5)  loss  of  all  subjacent  reflexes. 


308    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL   CORD. 

The  course  of  the  disease  is  usually  slow,  but  tubercle  and 
gummas  may  develop  with  great  rapidity. 

Tumors  of  the  spinal  cord — diagnosis :  This  is  often  uncer- 
tain. It  is  based  upon  the  slow  onset  and  gradual  develop- 
ment of  the  symptoms,  associated  with  symptoms  of  nerve- 
root  irritation.  If  malignant  growth  or  tubercular  disease 
exists,  or  has  existed  elsewhere  in  the  body,  or  there  is  a  his- 
tory of  previous  syphilitic  infection,  the  diagnosis  is  rendered 
much  simpler. 

It  may  be  confounded  with  myelitis  and  compression  of  the 
cord  due  to  vertebral  caries.  In  the  former  there  is  no  pain 
unless  associated  with  meningitis,  in  which  event  there  are 
diffuse  pain  and  hypersesthesia,  and  the  sphincters  are  usu- 
ally earlier  affected.  In  the  latter,  evidences  of  bone-dis- 
ease— i.  e.,  kyphosis,  pain  on  movement  or  jarring,  etc. — are 
present.  The  location  of  the  growth  is  determined  by  apply- 
ing the  rules  given  for  spinal  localization  (see  pp.  284-293). 

Brown-Sequard  paralysis,  followed  by  paraplegia  and  areas 
showing  dissociation  of  sensation  and  limited  early  muscular 
atrophy,  points  toward  tumor  situated  within  the  cord.  The 
nature  of  the  growth  is  determined  by  the  previous  existence 
of  malignant  or  tubercular  disease  elsewhere ;  or  to  the  ex- 
istence of  a  tubercular  diathesis  or  previous  syphilitic  infection. 

Prognosis :  Unless  the  tumor  can  be  removed,  this  is  fatal ; 
death  finally  occurring  from  exhaustion,  due  to  bedsores  and 
cystitis. 

Tumors  of  the  spinal  cord — treatment :  Except  in  the  case 
of  gumma,  when  specific  treatment  is  applicable,  medical 
treatment,  excepting  for  the  relief  of  symptoms  (see  Myeli- 
tis), is  of  no  avail.  If  the  tumor  is  recognized  early  and  is 
situated  without  the  cord-substance,  it  may  be  removed  by 
surgical  operation.  Even  then,  if  malignant  or  tubercular, 
return  is  probable.  Out  of  twenty-two  cases  collected  by 
Starr,  there  were  six  recoveries. 

SYRINGOMYELIA. 

Definition  :  Tliis  term  is  applied  to  the  symptoms  caused  by 
an  acquired  enlargement  of  the  central  canal,  or  to  the  forma- 
tion of  new  canals  in  the  yrav  matter  of  the  cord. 


SYRINGOMYELIA.  309 

Etiology  :  The  disease  is  rare.  It  usually  develops  early  in 
life,  twenty  to  thirty,  especially  in  men  exposed  to  hard  labor. 
The  etiology  is  obscure.  Some  cases  appear  to  be  caused  by 
trauma,  in  which  instance  there  is  primarily  hemorrhage  into 
the  gray  matter  ;  toxsemia,  as  the  infectious  diseases  ;  disease 
of  the  bloodvessels  producing  softening ;  but  the  majority  are 
probably  due  to  a  congenital  dislocation  of  some  of  the  e2ien- 
(Jymal  cells  which  are  normally  found  in  the  central  canal, 
which  proliferate  and  finally  degenerate. 

Morbid  anatomy  and  pathology :  The  usual  seat  of  the  cav- 
ity is  in  the  cervical  region,  but  it  may  be  limited  to  other 
situations  or  extend  throughout  the  length  of  the  cord,  even 
into  the  medulla.  It  may  extend  irregularly  in  a  transverse 
direction  backward  into  the  posterior  horns  or  forward  into 
the  anterior  horns,  or  be  merely  a  concentric  dilatation  of 
the  central  canal  (Figs.  67  and  68).  The  cavity  is  bounded 
by  neuroglia-tissue,  which  is  increased  in  amount  (gliosis),  and 
solid  masses  of  this  tissue  may  be  present  above  and  below 
the  cavity.  In  some  cases  there  is  extensive  gliosis,  with 
slight  or  no  cavity-formation  ;  while  in  others  the  cavity  is 
extensive  and  the  amount  of  gliosis  slight.  Sometimes  the 
cavity  appears  to  have  developed  independently  of  the  cen- 
tral canal,  but  communicates  with  it.  Secondary  degenera- 
tions in  the  ascending  tracts  above,  and  in  the  descending 
tracts  below  the  seat  of  the  process,  are  usually  present. 

Syringomyelia — symptoms :  The  symptoms  come  on  insidi- 
ously and  develop  slowly,  and  that  which  is  first  noticed  is 
usually  a  bilateral  atrophy  and  weakness  of  the  muscles  of 
the  hands  and  arms,  resembling  in  its  distribution  and  clinical 
features  that  observed  in  chronic  poliomyelitis  (which  see). 
Barely  one  side  only  may  be  afPected.  Examination  will  re- 
veal areas  in  which  there  are  loss  of  the  perception  of  pain 
and  temperature  with  preservation  of  tactile  and  muscle- 
sense  (dissociation  of  sensation). 

Also  temperature-sense  alone  may  be  lost  in  certain  areas. 
Areas  may  be  found  in  which  it  is  not  completely  lost,  but 
cold  may  be  perceived  and  heat  not,  or  i^ice  versa ;  or  cold 
may  be  felt  as  heat,  and  vice  versa  (Fig.  69).  The  loss  of 
sensation  occurs  in  zones,  and  does  not  follow  the  anatomical 
distribution  of  the  nerves,  as  in  neuritis. 


310     FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL  CORD. 

Fig.  67. 


Transverse  section  of  the  cervical  cord  in  a  case  of  syringomyelia,  showing  gliosis 
vsrith  extensive  cavity-formation.  The  lateral  tracts  are  also  seen  degenerated. 
Carmine  stain.    (From  specimen  loaned  by  Dercum.) 


Transverse  section  of  lumbar  cord,  showing  gliosis  with  formation  of  cavity  be- 
tween posterior  horns  and  posterior  to  central  canal,  the  remains  of  which  can 
be  seen  to  be  distinct  from  cavity.  Degeneration  of  lateral  tracts.  Weigert 
stain. 

Parsesthesias  of  various  sorts  and  pain  referable  to  the 
arms,  neck,  and  other  parts  of  the  body  may  be  complained 
of.     The  sensory  symptoms  (anaesthesia)  are  probably  present 


SYRINGOMYELIA. 


311 


before  the  development  of  motor  symptoms,  but  escape  notice 
by  the  patient. 

When  the  back-muscles   become  weak  scoliosis  develops. 
As  secondary  degenerations  take  place  symptoms  of  spastic 

Fig.  69. 


Sensory  chart  of  patient  shown  in  Fig. 
showing  areas  of 


Thermo- Anaesthesia,  %sSi 
j  and  Analgesia 


^^^1^  Thermo-Anaesthesia,  ||||||  Analgesia 
Tactile  Anaesthesia    and  areas  in  which  the  pa- 


tients answer  to  tests  of  temperature  showed  reversal 


Cold-Hot; 
Hot-Cold. 


paraplegia  develop,  if  limited  to  the  pyramidal  tracts ;  of 
ataxia,  if  confined  to  the  posterior  columns ;  and  of  ataxic 
paraplegia,  if  both  are  involved.  Trophic  symptoms  are 
common,  as  arthropathies,  most  common  in  the  arms ;  fract- 
ures of  the  bones  from  slight  causes ;  facial  hemiatrophy ; 
hypertrophy  of  the  bones  of  the  arms  ;  and  skin  eruptions 
and  ulcerations.  A  special  type  of  syringomyelia  has  been 
described  in  which  painless  felons  with  bone  necrosis  occur ; 
this  has  been  known  as  Morvan's  disease.     Vasomotor  dis- 


312    FOCAL  AND  DIFFUSE  DISEASES  OF  SPINAL  CORD. 

turbances,  as  lividity,  coldness,  excessive  sweating,  etc.,  also 
are  frequent.  If  the  seat  of  the  lesion  is  low  down  (lumbar 
region),  atrophy  would  occur  in  the  muscles  of  the  legs.  If 
it  extends  to  tlie  medulla,  bulbar  symptoms  occur.  Pupils 
unequal  and  contracted,  due  to  injury  to  the  cilio-spinal 
centre,  slight  ptosis,  and  nystagmus  may  also  be  present. 
Bedsores,  cystitis,  and  sphincter  paralysis  come  on  late  in  the 
course  of  the  disease. 

Diagnosis :  At  one  time  dissociation  of  sensation  was 
thought  to  be  pathognomonic  of  syringomyelia.  We  now 
know  that  this  phenomenon  may  occur,  although  rarely,  in 
other  disorders  which  affect  the  posterior  nerve-roots,  as  ver- 
tebral caries,  cervical  pachymeningitis,  tabes,  spinal  tumor, 
and  also  in  myelitis,  multiple  sclerosis,  disease  of  the  periph- 
eral nerves,  and  hysteria. 

The  diagnosis  must  be  made  from  these  and  also  from  pro- 
gressive muscular  atrophy  and  ansesthetic  leprosy.  Vertebral 
caries,  tabes,  multiple  sclerosis,  neuritis,  and  hysteria  can  be 
easily  distinguished  by  the  other  symptoms  present  in  these 
affections. 

Cervical  pachymeningitis,  tumor,  and  a  focal  myelitis  may 
be  more  difficult. 

Cervical  pachymeningitis  causes  more  severe  pain,  and 
twitchings  and  spasms  of  the  muscles  occur.  A  tumor  situ- 
ated in  the  gray  matter  may  be  indistinguishable.  Those 
springing  from  the  membranes  would  likely  cause  more 
severe  pain,  and  would  not  produce  the  development  of 
the  peculiar  trophic  symptoms  of  syringomyelia. 

Focal  myelitis  may  also  prove  difficult,  but  the  more  rapid 
development,  Avith  following  retrogression  of  the  symptoms, 
will  usually  distinguish  it. 

Chronic  poliomyelitis  is  distinguished  by  the  absence  of 
sensory  symptoms. 

In  leprosy  there  is  not  sensory  dissociation,  and  other 
symptoms  of  that  disease  will  appear. 

Syringomyelia — prognosis :  This  as  regards  cure  is  bad,  no 
known  measures  having  any  influence  upon  the  course  of  the 
disease.  Intervals  of  improvement  may  occur  temporarily. 
The  progress  is  slow,  lasting  many  years. 

The  treatment  is  purely  symptomatic. 


CHAPTER    XIII. 

DIFFUSE  DISEASES  AFFECTING  THE  BRAIN  AND  CORD. 

MULTIPLE   SCLEROSIS. 

Definition  :  Multiple  sclerosis,  also  known  as  insular  sclero- 
sis, disseminated  sclerosis,  a::d  sclerose  en  plaques,  is  a  chronic 
afiFection  characterized  by  localized  areas  of  sclerosis  usually 
scattered  throughout  the  brain  and  cord,  but  sometimes  lim- 
ited to  either  one  or  the  other. 

Etiology:  It  may  be  due  to  the  followino;  causes  :  exposure 
to  cold  and  wet;  traumatism;  emotional  depression;  infec- 
tious diseases  ;  chronic  metallic  poisoning,  and  overwork.  It 
is  believed  by  some  authors  (Striimpell,  B.  Sachs)  that  in 
many  cases,  especially  those  occurring  early  in  life,  there  is 
some  defect  in  the  original  development  of  the  nervous  sys- 
tem which  acts  as  a  predisposing  cause. 

It  is  a  disease  of  early  life,  the  majority  of  cases  occur- 
ring previous  to  the  age  of  thirty,  and  some  even  in  child- 
hood.    It  is  not  very  common. 

Morbid  anatomy  and  pathology :  The  sclerotic  areas  are  of 
irregular  size,  and  may  be  found  in  any  part  of  the  nervous 
system,  but  are  more  frequent  in  the  dorsal  half  of  the 
pons,  the  medulla,  in  the  white  matter  near  the  periphery  of 
the  cord,  and  the  gray  matter  near  the  central  canal. 

MaeroscopU'.ally,  the  sclerotic  areas  are  of  a  bluish-gray 
appearance,  and  may  appear  either  slightly  elevated  or 
shrunken  and  contracted. 

llicroscopieally,  there  is  found  thickening  of  the  walls  of 
the  bloodvessels,  with  contraction  of  the  lumen,  and  the 
perivascular  lympli-spaces  are  filled  with  cells.  Around  the 
diseased  vessels  the  neuroglia  is  proliferated,  and  in  the  cen- 
tre of  the  foci  the  neuroglia-cells  are  much  increased.  The 
myelin-sheaths    have    disappeared ;    the    axis-cylinders    are 


314    DIFFUSE  DISEASES  AFFECTING  BRAIN  AND  CORD. 

apparently  normal,  excepting  in  the  later  stages,  wlien  tliey 
may  degenerate.  It  is  only  then  that  secondary  degenera- 
tions occur.  The  ganglion-cells  also  show  evidences  of 
degeneration.  There  is  difference  of  opinion  as  to  the  pri- 
mary seat  of  the  process.  In  most  cases,  those  due  to  toxse- 
mia,  infection,  or  injury,  it  is  probably  the  bloodvessels ;  in 
others,  those  due  to  exhaustion  and  emotion,  the  nerve-ele- 
ments are  probably  first  affected. 

Multiple  sclerosis — symptoms :  Owing  to  the  different  dis- 
tribution of  the  sclerotic  areas  in  different  cases  the  symptoms 
vary,  but  there  are  certain  ones  sufficiently  constant  to  be 
considered  as  characteristic.  Usually  the  first  symptom 
noticed  is  weakness  of  one  or  more  limbs,  usually  both  legs, 
which  become  spastic,  with  great  increase  of  the  deep  reflexes. 
Soon  a  coarse  tremor,  developed  only  when  muscular  move- 
ments are  made,  appears  in  the  arms,  and  may  afterward  in- 
volve the  head  and  legs.  It  is  not  present  when  the  parts 
are  at  rest.  It  frequently  becomes  so  coarse  as  to  be  indis- 
guishable  from  ataxic  movements.  Nystagmus,  spontaneous 
or  only  developed  by  movements  of  the  eyes,  is  a  common 
symptom.  Optic  atrophy  is  frequently  present,  and  also 
paralyses  of  the  motor  nerves  of  the  eye  (see  Ophthalmo- 
plegia). Argyll-Robertson  pupil  occurs  rarely.  Other 
cranial  nerves,  as  the  fifth,  seventh,  and  twelfth,  may  also  be 
involved.  Speech  is  usually  affected,  the  patient  in  most 
cases  articulating  in  a  slow,  sing-song  manner  similar  to  that 
employed  in  scanning  a  line  of  poetry  (staccato  utterance — 
scanning  speech).  But  other  forms  of  dysarthria  resembling 
those  of  either  paretic  dementia,  Friedreich's  ataxia,  or  bulbar 
palsy  may  occur.  Patients  may  also  be  subject  to  attacks  of 
vertigo,  epileptiform  or  apoplectiform  seizures.  Muscular 
wasting  sometimes  occurs ;  as  does  also  anaesthesia,  either  in 
small  patches  or  as  a  hemianesthesia.  Various  forms  of  par- 
sesthesias  may  also  be  met  with. 

The  cardinal  symptoms  may  be  tabulated  as  follows 
(Peterson) : 

1.  Muscular  weakness  with  rigidity,  taking  a  hemlplegic, 
paraplegic,  or  monoplegic  form  ;  sometimes  with  cranial  nerve 
paralysis ; 

2.  "  Intention-tremor ''; 


MULTIPLE  SCLEROSIS.  315 

3.  Exaggerated  knee-jerks,  wrist-jerks,  with  ankle-clonus, 
possibly  jaw-jerk  ; 

4.  Nystagmus ; 

5.  Various  symptoms  of  nervous  disturbances,  as  vertigo, 
headache,  epileptiform  and  apoplectiform  attacks,  and  mental 
dulness ; 

6.  Disorders  of  speech. 

If  the  sclerotic  areas  are  few,  the  disease  may,  according 
to  their  location,  simulate  any  of  the  system  diseases,  the 
symptoms  characteristic  of  multiple  sclerosis  not  developing 
for  several  years  or  possibly  not  at  all.  The  symptoms  may 
be  entirely  cerebral  (cerebral  form) ;  or  entirely  spinal  (spinal 
form).     Remissions  are  very  apt  to  occur. 

Multiple  sclerosis — diagnosis :  It  may  be  confounded  with 
cerebro-spinal  sypMUs,  which  often  possesses  many  symptoms 
in  common  with  multiple  sclerosis.  Nystagmus,  scanning 
speech,  and  intention-tremor  are  rare  in  syphilis ;  while  in 
syphilis  there  are  peculiar  pupillary  symptoms,  as  absolute 
immobility,  unilateral  mobility,  and  irregular  contour  of  the 
pupils  (B.  Sachs). 

Paralysis  agitans  is  a  disease  of  old  age,  and  the  tremor  is 
present  when  the  parts  are  at  rest.  Nystagmus  and  scanning 
speech  are  absent. 

Hysteria  may  be  confounded.  Hysterical  syniptoms  may 
be  present  in  true  multiple  sclerosis.  In  hysteria,  however, 
a  true  intention-tremor  is  rare,  scanning  speech,  nystagmus, 
and  optic  atrophy  are  absent,  and  some  of  the  various  hys- 
terical stigmata  are  present. 

Cases  occurring  in  early  life  must  be  diiferentiated  from 
the  infantile  cerebral  palsies.  The  paraplegic  forms  can 
usually  be  distinguished  by  their  early  onset,  occurrence  of 
convulsions,  and  more  marked  defect  of  mental  development. 
The  diplegic  type  presents  more  difficulty,  as  nystagmus, 
peculiar  ataxic  movements,  and  speech-disturbances  may  be 
]>resent.  It  is  rare,  however,  for  more  than  one  of  these 
symptoms  to  be  present  in  diplegia.  The  onset  is  earlier  in 
life,  and  the  paralysis  and  contractures  more  marked. 

Friedreich's  ataxia  is  distinguished  by  absence  of  reflexes, 
optic  atrophy,  and  the  presence  of  ataxia  of  the  lower  limbs. 

Hereditary  cerebellar  ataxia  presents  more  difficulty.    The 


316     DIFFUSE  DISEASES  AFFECTING  BEAIN  AND   COED. 

diagno,<is  may  be  impossible  before  autopsy.  The  Romberg 
symptom,  present  in  cerebellar  ataxia,  is  rare  in  multiple 
sclerosis. 

Multiple  sclerosis — prognosis  :  The  disease  is  incuraI)lo,  but 
of  slow  progressit)u.  Remissions  occur,  and  sometimes  more 
or  less  permanent  improvement. 

Tlie  treatment  is  symptomatic.  Arsenic  and  silver  nitrate 
have  been  recommended. 

SYPHILIS  OF  THE  NERVOUS  SYSTEM. 

General  considerations  :  The  morbid  conditions  of  the  nervous 
system  due  to  syphilis  may  be  divided  into  two  groups — i.  e., 
the  specific  and  the  pardsi/phi/ific.  The  former  are  specific 
lesions  characteristic  of  syphilis  alone. 

The  latter  term  is  applied  to  the  states  in  which  the  lesions 
are  not  those  characteristic  of  syphilis,  but  which  are  due  in 
some  way  to  the  action  of  the  specific  poison,  which  may  thus 
cause  disorder  of  the  general  health,  lessen  the  vital  resist- 
ance, affect  the  developuient  of  the  foetus  and  infant,  and 
create  organic  defects  or  morbid  tendencies.  Such  affections 
are,  first,  those  due  to  acquired  syphilis — tabes  dorsalis, 
paretic  dementia,  neurasthenia,  and  hysteric,  epileptic,  and 
mental  disorders ;  second,  those  due  to  hereditary  syphilis, 
viz.,  juvenile  tabes  and  paresis,  hydrocephalus,  arrest  of  de- 
velopment of  parts  of  the  nervous  system,  as  possibly  some 
cases  of  Little's  disease,  and  the  hereditary  form  of  the  cere- 
bral palsies  of  childhood,  arrest  of  mental  development,  etc. 

The  symptoms  of  the  parasyphilitic  affections  are  described 
elsewhere. 

The  specific  forms  follow  either  acquired  or  hereditary  syph- 
ilis. In  the  former,  they  may  occur  at  varying  periods  of  time 
after  the  appearance  of  the  primary  sore.  The  usual  period 
is  between  the  third  and  tenth  years  :  but  cases  have  been  re- 
corded as  occurring  during  the  secondary  period,  even  before 
the  chancre  has  healed,  on  the  one  hand  ;  and  as  late  as  thirty 
years  after  infection,  on  the  other  hand. 

In  the  latter,  they  may  either  be  present  at  birth  or  may 
appear  during  childhood.  Rarely  their  appearance  may  be 
delayed  until  late  in  life.  All  parts  of  the  nervous  system 
may  be  affected  either  singly  or  collectively. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  317 

Morbid  anatomy  and  pathology  :  The  specific  lesions  of  syph- 
ilis found  iu  the  nervous  system  are  : 

Gummata;  which  form  deiinite  single  or  multiple  tumors. 
They  iire  usually  attached  to  the  pia,  and  may  either  finally 
invade  the  subjacent  cortex  or  else  only  compress  it.  They 
appear  to  spring-  from  the  walls  of  the  bloodvessels,  being 
composed  of  round  cells  derived  from  them  and  of  proliferated 
connective-tissue  cells.  The  walls  of  the  vessels  are  thickened 
by  these  proliferated  cells.  Gummatous  meningitis  usually 
coexists.  Occasionally  they  are  attached  to  the  dura  ;  and 
still  more  rarely  are  found  in  the  cerebral  substance,  when 
they  are  attached  to  a  ^'essel.  They  are  not  so  common  in 
the  cord  as  in  the  brain,  where  they  are  usually  found  in  the 
cerebral  cortex  or  about  the  pons. 

Gummatous  meningitis  ;  in  which  the  membranes  are  thick- 
ened and  infiltrated  with  cells  to  a  greater  or  less  extent.  The 
arteries  are  also  thickened.  It  is  alwavs  found  in  the  neiarh- 
borhood  of  the  large  growths  above  described,  but  may  occur 
without  them.  Gummatous  meningitis  is  more  apt  to  involve 
the  dura  than  is  the  localized  gumma.  It  is  most  commonly 
found  at  the  base. 

Diseases  of  the  bloodvessels;  which  occur  as  («)  endarteriUs 
obliterans,  in  which  there  is  great  proliferation  of  cells  in  the 
endothelial  and  subendothelial  tissues,  which  is  greatly  thick- 
ened, and  narrows  and  sometimes  obliterates  the  lumen  of  the 
vessel.  The  other  coats  are  also  infiltrated.  This  may  be 
also  due  to  other  causes. 

(b)  Gummatous  peri-arteritis,  in  which  nodular  gummata  de- 
velop in  the  adventitia  of  the  vessel,  producing  globular  or 
ovoid  swellings.     The  intima  may  or  may  not  be  involved. 

As  secondary  consequences  of  bloodvessel-disease,  we  have 
softening  due  to  thrombosis  in  or  obliteration  of  the  vessel's 
lumen,  rupture,  and  consequent  hemorrhage,  and  the  devel- 
o])ment  of  aneurism. 

It  is  a  strange  fact  that  patients  in  whom  the  secondary 
symptoms  have  been  mild  are  especially  likely  to  develo]> 
syphilis  of  the  nervous  system. 

Symptoms  :  As  all  parts  of  the  nervous  system  may  be  the 
seat  of  the  specific  lesion,  the  symptoms  perforce  are  varied 
and  widespread.     Consequently  it  is  impossible  to  set  up  rigid 


318    DIFFUSE  DISEASES  AFFECTING  BRAIN  AND  CORD. 

clinical  types.  But  it  is  a  fact  that  certain  parts  of  the  ner- 
vous system  are  more  liable  to  be  involved,  and  consequently 
certain  symptom-groups  are  more  constantly  present.  The 
symptoms  are  peculiar  in  tluit  they  are  often  transitory  and 
shifting,  appearing  suddenly  and  then  disappearing  in  a  few 
days,  others  taking  their  place ;  that  marked  remissions  may 
occur ;  and  that  paralysis,  when  it  occurs,  is  apt  to  be  incom- 
plete. Tlie  symptoms  commonly  produced  by  syphilitic 
lesions  will  be  briefly  detailed : 

Cerebral  syphilis :  One  of  the  earliest  symptoms  is  head- 
ache, which  is  constant,  severe,  and  often  becomes  worse  at 
night.  Disturbances  of  sleep  are  also  common.  These  may 
take  the  form  either  of  insomnia,  often  accompanied  by  irri- 
tability, or,  what  is  more  frequent,  excessive  somnolence, 
which  may  be  so  pronounced  as  to  cause  the  patient  to  fall 
asleep  at  his  work,  and  consequently  unfits  him  for  business. 
In  extreme  cases  he  seems  to  be  in  a  state  of  stupor,  wander- 
ing aimlessly  about,  seemingly  without  knowledge  of  where 
he  is.  He  seems  a  restless  nocturnal  automaton  rather  than 
a  man  (H.  C.  Wood).  From  tins  state  he  may  pass  into 
profoiuid  coma,  in  which  death  may  occur,  but  from  which 
recovery  is  possible. 

As  has  been  said,  the  inflammation  is  more  apt  to  take 
place  at  the  base,  in  M'hich  event  the  cranial  nerves  in  the 
neighborhood  would  suffer  from  pressure  or  infiltration  of 
their  sheaths,  causing  paralysis  (see  Cranial  Nerve  Palsies). 

When  the  optic  nerve  is  attacked,  among  other  symp- 
toms (see  Hemianopsia),  neuritis  of  it  is  frequently  caused, 
which  is  usually  very  acute,  differing  in  this  respect  from  that 
due  to  cerebral  tumor. 

The  motor  nerves  of  the  eye  are  also  especially  liable  to  be 
involved  in  various  degrees.  The  pupils  frequently  are  found 
to  be  immobile  (B.  Sachs).  Paralysis  of  the  cranial  nerves 
may  also  be  due  to  a  gumma  involving  their  nuclei. 

As  involvement  of  the  arteries  at  the  base  usually  coexists, 
gross  paralyses,  due  to  tln'oniboses  or  hemorrhages,  as  hemi- 
plegia, a])hasia,  etc.,  frequently  occur.  Thrombosis  is  more 
comuion  than  hemorrhage  (see  Apoplexy). 

AVhen  the  ])i-ocess  involves  the  convexity,  symptoms  due 
to  involvemeut  of  the  cortical  centres  appear,  which  are  focal 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  319 

in  character.  In  widespread  involvement  of  the  cortex  gen- 
eral epileptiform  convulsions  are  often  suffered  (see  Epilepsy). 
This  may  also  be  a  parasyphilitic  disease.  Diffuse  syphilis 
of  the  cortex  may  also  cause  symptoms  resembling  those  of 
paretic  dementia  (which  see). 

While  the  symptoms  of  brain  syphilis  are  usually  of  gradual 
onset,  they  may  appear  suddenly,  with  the  rapid  development 
of  coma,  which  may  or  may  not  be  accompanied  by  convul- 
sions, delirium,  and  various  forms  of  paralysis,  resembling 
sometimes  apopleptic  attacks. 

Acute  forms  of  msanity  may  come  on  at  any  stage  of  syph- 
ilis, especially  in  the  early  stages.  Hi/pocJiondria  and  mental 
depression  may  occur ;  and  may  be  modified  or  interrupted  by 
attacks  of  mania  or  melancholia,  and  finally  pass  into  de- 
mentia or  remain  constant.  These  cases  are  often  due  to  the 
toxic  condition  of  the  blood  following  the  primary  infection. 
Maniacal  conditions  may  also  occur  in  the  course  of  mental 
decay  or  derangement  produced  by  intracranial  syphilitic 
lesions  of  the  late  stage.  Frequently  such  attacks  follow  con- 
vulsive seizures  caused  by  organic  syphilitic  disease  (Mickle). 

Syphilis  of  the  cord :  The  symptoms  of  syphilis  of  the  cord 
resemble  those  of  syphilis  of  the  brain  in  their  variability 
and  tendency  to  remissions,  there  being  no  one  symptom- 
group  which  can  be  said  to  be  characteristic.  Erb  has  de- 
scribed a  special  complex  of  symptoms  which  occurs  some- 
what frequently,  and  which  is  known  as  Erb's  type  of  syphi- 
litiG  spinal  paralysis. 

This  usually  begins  with  slowly  increasing  weakness  and 
stiffness  of  the  lower  extremities,  frequently  accompanied  by 
paresthesias  of  the  legs,  back,  and  anal  region.  Actual  pain 
is  rare,  but  may  occur  as  girdle  pain  on  scattered  areas  in 
other  parts  of  the  body.  Anaesthesia  practically  never  occurs, 
but  diminution  of  one  or  all  forms  of  sensibility  may  occur. 
Some  incodrdination  and  Romberg's  symptom  may  be  pres- 
ent. Disturbance  of  the  bladder  function,  usually  mani- 
fested by  difficulty  in  passing  water  ;  constipation,  and  loss 
of  sexual  power  are  usually  early  symptoms.  When  fully 
developed,  the  symptoms  are  a  spastic  paralysis  of  the  legs, 
greater  than  would  seem  warranted  by  the  rigidity  of  the 
muscles,  which    is    not    marked  ;    increased    knee-jerks    and 


320    DIFFUSE  DISEASES  AFFECTING  BRAIN  AND   COED. 

ankle-cloiiiis,  difficulty  In  micturition,  constipation,  and  loss 
of  sexual  power,  without  anaesthesia  or  muscular  atrophy. 

In  these  cases  the  lesion  is  probably  in  the  lower  half  of 
the  dorsal  cord,  involving  chiefly  the  posterior  parts  of  the 
lateral  columns ;  less  so  the  posterior  columns  and  horns. 
The  spastic  gait,  without  proportional  muscular  rigidity  and 
contracture,  distinguish  this  from  other  forms  of  spinal 
paralysis  (ataxic  paraplegia,  lateral  sclerosis,  transverse  mye- 
litis, etc.). 

If  the  lesion  consists  of  a  localized  gumma,  the  symptoms 
are  those  of  spinal  tumor.  An  area  of  softening  in  the  gray 
matter  may  produce  symptoms  simulating  syringomyelia. 
In  some  instances  they  simulate  those  of  tabes  dorsalis  ;  in 
others  the  Brown-Sequard  syndrome  may  be  present.  Gum- 
mata  may  invt)lve  the  cauda  equina.  These  symptoms  are 
due  to  gummatous  exudation,  aud  arterial  disease,  as  are  those 
of  cerebral  syphilis,  and  may  coexist  with  them. 

Syphilis  of  the  nerves  :  The  cranial  nerves  may  be  attacked 
primarily,  especially  the  optic  and  motor  nerves  of  the  eye, 
causing  ophthalmoplegia.  The  spinal  nerves  are  but  very 
rarely  involved,  unless  it  is  involvement  of  their  roots  by  a 
syphilitic  exudation,  when  the  symptoms  of  nerve-root  irrita- 
tion and  compression  (see  Meningitis)  will  be  caused. 

Syphilis  of  the  nervous  system — diagnosis :  If  obtaining  a 
history  of  previous  syjihilitic  infection  is  not  possible,  the 
evidences  of  it  upon  the  person,  or  a  history  on  the  part  of 
the  wife  of  frequent  miscarriages,  stillborn  children,  or 
deaths  in  early  infancy,  are  suggestive.  It  is  important  to 
remember  the  frequent  lightness  of  the  secondary  symptoms 
in  those  who  develop  nerve  syphilis.  The  diagnosis  is  based 
on  the  multi])licity  of  the  lesions,  their  peculiar  progress — 
i.  e.,  their  fugacious  character  and  frequent  remissions — and 
the  general  subacute  character  of  the  affection.  In  the  ab- 
sence of  hysteria,  any  indefinite  and  apparently  disconnected 
series  of  nerve  accidents  is  of  very  urgent  import  (H.  C. 
"Wood).  The  age  of  the  patient  is  suggestive.  Apoplexy, 
not  due  to  embolism,  occurring  in  early  adult  life  is  mostfre- 
quentlv  due  to  syphilis;  and  (']>ileptiform  attacks  occurring 
after  thirty-five  are  most  frequently  so  caused  (see  Epilepsy). 


SYPHILIS   OF  THE  NERVOUS  SYSTE3I  321 

Cases  of  sudden  (;onia  due  to  syphilis  present  great  difficulty. 
All  other  causes  of  coma  must  be  eliminated,  A  pronounced 
rise  of  temperature  or  conjugate  deviation  tells  against ;  while 
ocular  palsies  or  partial  paralysis  of  any  chaiacter  argues  in 
favor  of  a  specific  origin  (H.  C.  Wood). 

Previous  to  the  development  of  the  more  permanent  symp- 
toms a  previous  history  of  headache,  insomnia,  or  somno- 
lence, transient  double  vision,  or  other  evidence  of  a  transient 
palsy,  may  often  be  obtained.  While  cord  syphilis  may  sim- 
ulate any  of  the  organic  diseases  of  the  cord,  some  atypical 
feature  will  generally  be  present,  as  absence  of  rigidity  and 
contractures  in  spastic  paralysis  ;  absence  of  Argyll-Robert- 
son pupil  in  tabetiform  cases,  etc.  Isolated  paralysis  of  any 
of  the  cranial  nerves,  points  to  syphilis  in  the  absence  of 
other  apparent  cause.  B.  Sachs  lays  stress  upon  the  frequent 
occurrence  of  immobility  of  the  pupil.  Often,  however,  our 
diagnosis  depends  for  certainty  upon  the  fact  that  the  symp- 
toms succumb  to  antisyphilitic  medication. 

Syphilis  of  the  nervous  system — prognosis  :  While,  on  the 
whole,  the  prognosis  in  cases  of  syphilis  in  the  nervous  sys- 
tem is  favorable,  it  is  not  always  so.  If  the  nerve-elements 
are  destroyed  by  the  lesion,  as,  for  instance,  by  a  cerebral  hem- 
orrhage, the  prognosis  is  no  better  than  that  of  similar  con- 
ditions due  to  other  causes.  Also,  while  a  gumma  may  be 
made  to  disappear  by  treatment,  it  may  leave  a  scar  in  the 
nerve-tissue  that  will  cause  permanent  symptoms.  Hence 
there  should  always  be  some  reservation.  In  any  case,  the 
prognosis  becomes  unfavorable  in  proportion  to  the  length  of 
time  that  the  symptoms  have  persisted  and  the  age  of  the 
patient.  Death  may  occur  during  a  syphilitic  convulsion  or 
attack  of  congestion,  or  from  the  involvement  of  some  vital 
centre. 

Syphilis  of  the  nervous  system — treatment :  In  cases  of 
coma,  if  there  is  much  arterial  excitement,  venesection  and 
measures  similar  to  those  employed  in  cerebral  hemorrhage 
should  be  employed.  In  feeble  cases,  milder  measures,  as 
cupping,  cold  to  the  liead,  and  sinapisms  to  the  extremities 
should  be  used.  For  the  treatment  of  the  disease  the  choice 
of  remedies  will  depend  upon  the  condition  of  the  patient. 
If  feeble  and  cachectic,  tincture  of  iron  and  bichloride  of 

21— N.  D. 


322    DIFFUSE  DISEASES  AFFECTING  BRAIN  AND  CORD. 

mercury  should  be  given.  In  robust  cases  a  rapid  action  is 
desirable,  and  the  employment  of  mercury  by  inunction  or 
hypodermatic  injection  until  constitutional  effects  are  mani- 
fest should  be  advised.  For  the  hypodermatic  injection  cor- 
rosive sublimate  in  doses  of  one-twelfth  of  a  grain  in  distilled 
water  is  a  convenient  form.  After  a  course  of  mercurials,  or 
along  with  it,  iodide  of  potassium,  in  increasing  doses  until 
iodism  results,  should  be  administered.  Combined  with  these 
measures  the  employment  of  tonics,  nutrients,  and  sympto- 
matic treatment  is  advisable. 


CHAPTER    XIV. 

GENERAL  AND  FUNCTIONAL  DISEASES. 

PARALYSIS  AGITANS. 

Etiology ;  This  disease,  also  known  as  Parkinson's  disease 
and  shaking  palsy,  usually  makes  its  appearance  between  the 
ages  of  forty  and  sixty -live  years.  Cases  have  been  reported 
in  which  it  appeared  much  earlier,  but  these  are  rare.  It  is 
more  common  in  males.  A  neuropathic  heredity  can  be  traced 
in  most  cases.  Fear,  anxiety,  exposure,  overwork,  grief,  and 
trauma  have  been  given  as  exciting  causes. 

Paralysis  agitans — symptoms :  Usually  the  first  symptom 
noticed  is  muscular  rigidity,  affecting  principally  the  flexors 
of  the  arms,  head,  trunk,  and  legs,  which  produces  the  char- 
acteristic position — i.  e.,  the  (Fig.  70)  head  and  body  are  bent 
forward,  the  fingers  flexed  as  a  whole  on  the  metacarpus,  the 
forearms  flexed  on  the  arms,  and  the  knees  slightly  bent. 
The  symptom  may  commence  on  one  side,  which  may  be 
affected  for  some  time  before  symptoms  appear  upon  the  other. 
Rarely  the  extensors  of  the  neck  are  affected,  causing  the 
head  to  be  drawn  backward.  Cramps  may  occur  and  there 
is  a  sense  of  stiffness.  Muscular  movements  are  slow.  The 
deep  reflexes  are  not  increased.  The  facies  is  characteristic, 
the  lines  of  expression  becoming  smoothed  out,  the  eyelids 
widely  opened  and  rarely  winking,  the  appearance  resembling 
that  of  a  face  covered  by  a  mask.  The  gait  is  peculiar,  the 
steps  being  short  and  shuffling,  often  with  a  hesitancy  in  start- 
ing ;  often  also  there  is  a  tendency  to  run  suddenly  forward, 
the  patient  appearing  to  hasten  his  steps  in  order  to  keep  up 
Avith  his  body,  which  is  held  advau'^ed  beyond  the  perpendic- 
ular (festination).  The  tremor  either  appears  after  the  rigidity 
or  about  the  same  time.  It  usually  commences  first  in  one 
hand  and  arm,  then  after  a  greater  or  less  period  of  time  in- 
vades the  leg,  and  finally  involves  the  other  side.    The  tremor 

323 


324 


GENERAL  AND  FUNCTIONAL  DISEASES. 


Fig.  70. 


is  slow,  and  the  patient  seems  to  be  constantly  rolling  some 
small  object  between  the  thumb  and  fingers.    It  is  worse  while 

the  limbs  are  at  rest,  and  usually 
ceases  for  a  few  moments  after 
voluntary  movement  is  begun. 
It  ceases  during  sleep.  The 
muscles  of  the  neck  aud  head 
are  but  rarely  affected.  Motor 
weakness  is  not  a  marked  symp- 
tom, and  usually  is  not  evident 
at  all  until  the  disease  is  of  long 
standing. 

The  sensory  symptoms  con- 
sist of  dull  pains  in  the  limbs 
and  a  feeling  of  heat.  Vaso- 
motor disturbances,  evidenced 
by  increased  surface-tempera- 
ture,sweating,  and  flushing,  may 
be  present.  The  mental  facul- 
ties, if  aroused  by  some  stimu- 
lation, are  not  much,  if  at  all, 
lessened ;  but  ordinarily  the 
patient  thinks  slowly,  is  apa- 
thetic, and  appears  to  take  no 
interest  in  his  surroundings. 
The  speech  becomes  hesitating 
and  monotonous. 

The  appearance  and  attitude 
of  a  patient  with  paralysis  agi- 
tans  are  well  shown  in  Fig.  70. 
The  course  of  the  disease  is  pro- 
gressive but  slow,  lasting  some- 
times as  long  as  forty  years. 
The  patient  may  eventually 
become  helpless  and  demented. 
Cases  occur  in  whicli  the  tre- 
mor is  absent,  the  diagnosis 
then  depending  upon  the  pe- 
culiar rigidity,  attitude,  facies,  etc. 

Morbid  anatomy :  While  paralysis  agitans  has  been  classi- 


Photograph  of  a  case  of  paralysis  agi- 
tans, showing  the  attitude,  the  posi- 
tion of  the  hands,  and  the  facie.". 


CHOREIFORM  AFFECTIONS.  325 

fied  under  functional  diseases,  recent  investigations  have 
tended  to  show  the  occurrence  of  a  fairly  constant  number 
of  anatomical  changes,  principally  in  the  spinal  cortls  of  these 
patients.  They  consist  of  congestion  and  dilatation  of"  ves- 
sels in  the  gray  matter,  atrophy  and  pigmentation  of  the  cells 
and  an  increase  of  interstitial  tissue.  The  central  motor 
neuron  appears  to  be  most  at  fault  (Dana). 

The  diagnosis  is  usually  not  difficult.  The  tremor  possesses 
a  feature  peculiar  to  that  of  this  disease  in  the  temporary 
cessation  which  occurs  after  voluntary  motion.  This  alone 
will  serve  to  distinguish  it  from  multiple  sclerosis,  which  in 
addition  differs  in  the  presence  of  increased  knee-jerks,  ankle- 
clonus,  nystagmus,  peculiar  speech,  etc.  Senile  tremor  occurs 
in  the  very  old,  and  usually  affects  the  head  first.  Post-hemi- 
plegic  tremor  is  distinguished  by  a  previous  history  of  an 
apoplectic  attack  and  the  presence  of  hemiplegia.  Other  causes 
of  tremor  and  their  characteristics  are  given  on  pp.  36-38. 

Prognosis :  The  disease  is  incurable,  but  may  last  a  long 
time,  and  remissions  sometimes  occur. 

Paralysis  agitans — treatment :  The  patient  should  lead  a 
quiet  life,  with  plenty  of  fresh  air  and  plenty  of  simj^le,  nu- 
tritious food.  Tonics,  such  as  quinine,  arsenic,  and  mineral 
acids  are  helpful.  Lukewarm  baths  and  electricity  in  the 
form  of  the  constant  current,  applied  daily,  have  also  been 
recommended.  One  of  the  best  drugs  for  relieving  the 
tremor  is  hyoscine  hydrobromate,  in  doses  of  gr.  y^  t.  i.  d., 
and  increased.  Codeine  is  also  useful  for  this  purpose. 
Gowers  recommends  cannabis  indica  and  arsenic. 

CHOREIFORM  AFFECTIONS. 

Sydenham's  Chorea. 

Definition :  Sydenham's  chorea,  chorea  minor,  St.  Vitus' 
dance,  St.  Anthony's  dance,  is  an  acute  functional  disease, 
occurring  principally  in  children,  and  is  characterized  by 
irregular  and  incoordinate  muscular  contractions  and  twitch- 
ings,  which  are  ordinarily  beyond  the  control  of  the  ^vill  and 
cease  during  sleep.  There  is  present  in  most  cases  more  or 
less  psychical  impairment  (Sinkler). 


326  GENERAL  AND  FUNCTIONAL  DISEASES. 

Etiology :  A  neuropathic  history  in  the  parents  or  relatives 
can  usually  be  traced.  The  majority  of  cases  occur  between 
the  ages  of  five  and  fifteen.  It  may  occur  younger.  Sinkler 
mentions  a  case  which  has  persisted  since  birth,  due  to  a 
fright  which  the  mother  received  during  pregnancy.  It  may 
also  come  on  in  adult  life  or  old  age,  when  it  is  known  as 
senile  chorea.  It  is  more  common  in  girls  than  boys.  Chorea 
is  more  common  in  the  city  than  in  the  country,  and  occurs 
most  frequently  in  the  spring  and  summer. 

The  relationship  between  chorea  and  rheumatism  is  well 
known.  Of  927  cases  analyzed  by  Sinkler,  there  was  a  his- 
tory of  rheumatism  in  20.1  per  cent.  The  interval  elapsing 
between  the  rheumatism  and  the  attack  of  chorea  varied  from 
immediately  preceding  to  six  years. 

Chorea  occasionally  follows  scarlatina.  Fright  is  a  fre- 
quent cause  of  the  attack.  Gowers  believes  that  it  is  the  cause 
in  one-fifth  of  the  cases.  Traumatism  may  occasionally  act 
as  a  cause.  Reflex  causes,  as  nasal  disease,  refractive  errors, 
adherent  prepuce,  either  of  the  penis  or  clitoris,  may  some- 
times develop  the  disease.  Overstudy  and  worry  are  fre- 
quent causes.  Choreic  children  are  frequently  an?emic  and 
badly  nourished.  Pregnancy  may  excite  an  attack  of  chorea, 
and  is  a  common  cause  in  adults.  This  form  is  known  as 
chorea  gravidarum.  It  is  most  common  in  primipara.  A 
history  of  previous  attacks  in  childhood  is  often  obtained 
from  these  patients. 

Sydenliam's  chorea — symptoms  :  Usually  the  first  symptom 
noticed  is  a  general  restlessness  and  inability  to  sit  still. 
Close  observation  will  also  show  twitching  of  the  fingers  of 
one  hand,  a  shrugging  of  tlie  shoulder,  or  drawing  of  the 
mouth  at  intervals.  If  the  child  attends  school,  it  will  be 
noticed  that  the  writing  deteriorates,  and  that  the  pencil  or 
other  objects  grasped  are  dropped  from  the  hand.  The  child 
becomes  peevish,  irritable,  and  emotional.  Dull  pains  in  the 
joints  are  often  complained  of,  and  headache  may  be  present. 
As  the  disease  advances,  the  movements  (the  characteristics 
of  the  choreic  movement  are  described  on  p.  38)  become 
more  marked  and  generalized,  but  do  not  always  involve  all 
the  muscles.  In  mild  cases  they  can  for  a  time  be  controlled 
by  the  will,  and  are  not  severe  enough  to  prevent  the  patient 


CHOREIFORM  AFFECTIONS.  327 

from  performing  voluntary  movements  such  as  dressing,  un- 
dressing, and  feeding  himself.  In  the  severe  cases  the  move- 
ments become  general ;  every  muscle  is  in  violent  action,  so 
that  it  may  be  impossible  for  the  child  to  sit  still.  In  some 
instances  it  is  necessary,  in  order  to  keep  the  patient  from  fall- 
ing out  of  bed,  to  surround  it  with  high  padded  sides  ;  or  to 
tie  him  by  means  of  a  sheet  passed  around  the  body  and  fas- 
tened to  the  bed.  Owing  to  the  irregular  contractions  of  the 
muscles  of  articulation,  speech  is  interfered  with.  In  the 
milder  cases  these  may  consist  of  talking  in  a  thick  and  in- 
distinct manner  and  a  spasmodic  jerking  out  of  words,  while 
in  very  severe  cases  the  patient  cannot  articulate  at  all. 

Contractions  of  the  laryngeal  muscles  sometimes  cause  in- 
voluntary explosive  sounds  to  be  uttered.  Rarely,  the  choreic 
movements  may  be  confined  to  these  muscles,  a  condition 
known  as  laryngeal  chorea.  The  face,  in  the  intervals  be- 
tween the  facial  movements,  assumes  a  blank  and  vacant  ex- 
pression. The  muscles  of  respiration,  especially  the  dia- 
phragm, are  also  sometimes  affected,  causing  irregular  respi- 
rations— sometimes  shallow,  sometimes  deep,  with  occasion- 
ally a  few  rapid,  shallow  respirations  and  then  a  long  sigh- 
ing one.  The  heart's  action  may  also  be  irregular.  During 
sleep  the  movements  usually  cease ;  but  the  sleep  is  restless 
and  enuresis  is  sometimes  suffered  from.  The  patient,  no 
matter  how  severe  the  movements,  seldom  complains  of  being 
tired. 

Muscular  weakness  may  exist,  shown  by  dragging  the  leg 
in  walking  or  a  weakening  of  the  grasp.  This  is  seldom  pro- 
nounced, but  in  rare  instances  the  paresis  is  a  more  marked 
symptom  than  the  movements  [paralytic  chorea^. 

Heart-murmurs  are  frequent.  These,  in  the  majority  of 
cases,  are  hsemic,  depending  upon  the  ansemic  condition  often 
found  in  these  cases.  The  murmur  is  usually  soft,  systolic,  and 
heard  at  the  apex.  Endocarditis  is  a  frequent  complication 
of  chorea;  it  is  usually,  however,  of  a  mild  type.  Of  110 
cases  examined  by  Osier,  two  years  and  longer  after  an  attack 
of  chorea,  54  presented  some  sign  of  organic  heart  disease. 
Pericarditis  is  an  occasional  complication.  During  the  attack 
the  temper  is  irritable,  there  are  frequent  hysterical  outbreaks, 
and  inability  to  study  or  apply  one's  self.     In  rare  instances 


328  GENERAL  AND  FUNCTIONAL  DISEASES. 

melancholia  or  acute  mania  may  occur.  Cases  of  violent 
choreic  movements,  usually  occurring  in  adult  women,  asso- 
ciated with  great  mental  excitement  and  delirium,  are  known 
as  chorea  insanieiis.  Convulsive  attacks  very  rarely  occur. 
The  knee-jerks  are  sometimes  absent,  but  are  capable  of  re- 
inforcement. Trophic  changes  are  shown  by  a  tendency  of 
slight  scratches  to  become  inflamed  and  wounds  heal  slowly. 
Various  skin-eruptions  as  herpes,  various  forms  of  purpura, 
erythema  nodosum,  and  the  formation  of  subcutaneous  fibrous 
nodules,  such  as  are  associated  with  rheumatism,  are  some- 
times met  with. 

The  attack  usually  reaches  its  maximum  in  about  two 
weeks,  and  its  duration  varies  from  three  weeks  to  three 
months  or  longer ;  the  average  being  ten  weeks.  Sometimes 
cases  become  chronic  and  continue  during  life.  Remissions 
during  an  attack  may  occur,  and  patients  who  have  had  one 
attack  are  liable  to  have  future  ones. 

Morbid  anatomy  and  pathology :  The  lesions  found  in  Syden- 
ham's chorea  are  cerebral  hypersemia,  with  dilatation  of  the 
vessels,  peri-arterial  exudations,  some  thickening  of  the  in- 
tima  of  the  small  arteries,  erosions,  spots  of  softening,  min- 
ute hemorrhages,  and  emboli.  They  are  found  in  the  motor 
tract,  particularly  the  lenticular  nuclei  and  thalami,  the  gray 
matter  of  the  cortex,  and  spinal  cord.  In  chronic  cases  peri- 
vascular dilatations  and  increase  of  connective  tissue  is  found. 
In  the  heart  evidences  of  endocarditis  may  be  present.  The 
cause  of  these  changes  is  not  known ;  but  is  probably  an 
infection  of  some  sort. 

Sydenham's  chorea — diagnosis  :  The  diagnosis  is  usually  not 
difficult. 

Hysterical  chorea  may  be  mistaken.  This  is  almost  always 
seen  in  young  adults ;  the  movements  are  more  rhythmical, 
and  frequently  they  consist  of  sudden  jerks,  like  those  caused  by 
electric  shocks.  They  increase  in  severity  when  the  patient 
is  under  observation.  Other  stigmata  of  hysteria  will  be 
present. 

Athetoid  and  choreiform  movements  occurring  in  cases  of 
infantile  cerebral  palsies  may  simulate  chorea,  especially  when 
the  paralysis  is  not  marked.  The  history  of  the  onset,  rigid- 
ity of  muscles,  increased  reflexes,  rhythmic  character  of  the 


CHOREIFORM  AFFECTIONS.  329 

movements  will  make  the  diagnosis  clear.  Facial  spasm  and 
habit-chorea  may  also  be  confounded  ;  the  distinguishing  feat- 
ures are  given  in  connection  with  the  descriptions  of  those 
disorders. 

t^cn'de  or  adult  chorea,  if  it  becomes  chronic,  may  be  com- 
founded  with  hereditary  chorea.  The  features  in  ^vhich  the 
two  differ  are  given  under  the  description  of  that  disease. 

As  regards  life,  the  prognosis  is  good.  Cases  of  chorea 
insaniens  occasionally  die.  The  disease  sometimes  becomes 
chronic.  If  it  has  lasted  over  six  months,  it  may  be  said 
to  be  so.  It  is  more  apt  to  do  so  in  cases  occurring  late  in 
life. 

Sydenham's  chorea — treatment:  All  sources  of  reflex  irri- 
tation, as  refractive  errors,  nasal  disease,  adherent  prepuce, 
must  be  sought  for  and  removed  if  found.  The  child  should 
be  removed  from  school  and  all  sources  of  excitement  avoided. 
The  diet  must  be  simple  and  nutritious,  tea,  coifee,  pastry, 
candy,  etc.,  being  avoided.  In  severe  cases  absolute  rest  in 
bed  is  essential,  and  with  this  gentle  massage  once  or  twice 
daily  is  beneticial.  The  patient  should  be  bathed  daily.  In 
milder  cases,  instead  of  absolute  confinement  to  bed,  the 
child  may  be  alloAved  to  be  up  and  in  the  air  part  of  the  day. 

Arsenic,  in  the  form  of  Fowler's  solution,  is  the  most  effi- 
cacious drug.  It  should  be  given  in  ascending  doses  until 
the  toxic  effects  of  the  drug  are  manifested,  when  it  may 
be  stopped  for  a  day  or  two,  and  then  continuing  with  the 
maximum  dose  that  will  not  produce  these  symptoms.  Large 
doses  of  quinine,  as  recommended  by  H.  C.  Wood,  are 
sometimes  useful.  Antipyrine,  cimicifuga,  and  monobromide 
of  camphor  may  prove  useful  in  some  cases.  Along  with 
these  drugs,  tonics  and  nutrients,  as  iron,  small  doses  of 
strychnine,  cod-liver  oil,  etc.,  are  usually  indicated.  In  the 
severe  cases  bromides,  chloral,  or  hydrobromate  of  hyoscine 
may  be  required  to  quiet  the  movements  and  promote  sleep. 

Habit-chorea. 

Habit-chorea  is  a  form  of  cliorea  occurring  in  children,  in 
which  the  movements  are  confined  to  a  localized  group  of 
muscles  ;  usually  those  of  the  face.     It  may  be  confined  en- 


330  GENERAL  AND  FUNCTIONAL  DISEASES. 

tirely  to  the  muscles  of  respiration,  causing  the  emission  of 
various  peculiar  sounds,  as  grunts,  incessant  cough,  etc. 

The  causes  are  similar  to  those  of  ordinary  acute  chorea. 

It  differs  from  spasm  of  the  facial  muscles  in  that  it  comes 
on  in  childhood,  the  movements  are  not  so  quick,  and  the  dis- 
ease responds  to  treatment,  which  is  similar  to  that  employed 
for  acute  chorea. 

Hereditary  Chorea. 

Synonyms — definition  :  This  disease,  also  known  as  chronic 
progressive  chorea  and  Huntington's  chorea,  occurs  in  suc- 
cessive generations  of  a  family,  making  its  appearance  in  the 
victims  in  most  cases  at  about  the  ages  of  thirty  to  forty, 
and  is  characterized  by  peculiar  general  rhythmic  movements 
and  mental  deterioration. 

Symptoms :  Previous  to  the  appearance  of  the  movements, 
the  patient  may  suffer  from  nervousness,  weakness,  and  loss 
of  ambition ;  and  difficulty  is  noticed  in  performing  fine 
movements,  as  writing.  The  movements  usually  first  appear 
in  the  upper  extremity,  resembling  those  of  chorea  minor. 
In  time  they  become  general,  involving  both  arms  and  legs ; 
and  speech,  which  is  slow  and  difficult,  and  swallowing  are 
interfered  with.  When  fully  developed,  the  movements  differ 
from  those  of  chorea  minor,  being  more  rhythmical  and 
more  extreme,  whole  groups  of  muscles  being  brought  into 
action.  The  gait  is  characteristic,  the  patient  taking  a  few 
steps  naturally,  then  makes  a  long  step  with  one  leg,  bring- 
ing up  the  other  quickly  to  it  and  making  one  or  two  hops, 
which  gives  the  appearance  of  dancing.  Sometimes  there 
is  a  tendency  to  stand  in  one  position  for  a  length  of  time. 
In  the  early  stages  the  movements  may  be  controlled  by  the 
will.  In  the  later  stages  effort  to  do  so  increases  them. 
Mental  disorder  is  found  in  all  cases.  Usually  it  appears 
late,  but  sometimes  it  precedes  the  motor  symptoms.  It 
usually  consists  of  mental  depression,  with  suicidal  tenden- 
cies, delusions  of  persecution,  with  the  development  of  de- 
mentia. 

MorMd  anatomy  and  pathology  :  The  principal  macroscopic 
change  is  an  atrophy  and  thinness  of  the  cortex,  and  in  some 


CHOREIFORM  AFFECTIONS.  331 

cases  evidences  of  meningitis.  Microscopically,  evidences  of 
a  slowly  progressive  degeneration  of  the  ganglion-cells  is 
found  most  marked  in  the  liolandic  region.  Slight  increase 
of  the  neuroglia,  distention  of  the  perivascular  spaces,  and 
slight  disease  of  the  bloodvessels  occur,  and  slight  degenera- 
tions in  the  pyramidal  tracts.  The  cause  is  probably  similar 
to  that  producing  Friedreich's  ataxia — i.  e.,  sl  premature  death 
of  the  cell,  owing  to  an  inherent  weakness. 

Hereditary  chorea — diagnosis  :  Friedreich's  ataxia  appears 
in  early  life  ;  the  movements  are  not  choreic,  but  ataxic;  the 
knee-jerks  are  absent ;  nystagmus  is  present.  In  multiple 
sclerosis  the  movements  cease  while  the  patient  is  at  rest. 

Prognosis :  The  disease  is  incurable,  but  it  may  last  a  long 
time  before  death  occurs. 

The  treatment  is  symptomatic.  Arsenic  and  nitrate  of  sil- 
ver may  be  tried.  Collins  advocates  giving  these  drugs  in 
the  largest  dose  possible,  and  for  a  long  period  of  time. 

Tic  Convulsif. 

Synonyms — etiology  :  This  disease  is  also  known  as  palmus 
and  Gilles  de  la  Tourette's  disease.  While  sometimes  mis- 
taken for  chorea,  particularly  habit-chorea,  it  is  really  a  psy- 
chosis allied  to  hysteria.  It  may  begin  as  early  as  the  sixth 
year.     A  neuropathic  ancestry  can  usually  be  traced. 

The  symptoms  consist  of:  (a)  Involuntary  muscular  move- 
ments, varying  from  slight  spasm  of  the  facial  muscles  (simple 
tic),  to  complex  movements  involving  all  the  muscles  of 
the  body.  The  muscles  of  the  face  are  most  commonly 
affected.  The  movements  sometimes  are  of  a  purposive  nat- 
ure, as  continual  scratching  on  one  part  of  the  body.  They 
are  increased  by  excitement. 

(6)  Livoldiitary  cries  and  explosive  utterances :  Sometimes 
the  words  used  are  of  a  profane  or  obscene  nature  (coprolalia) ; 
in  other  cases  there  is  an  irresistable  tendency  to  repeat  names 
or  sentences  heard  (echolalia\  Movements  made  by  other 
persons  may  also  be  imitated  (echokinesia). 

(c)  Many  cases  present  other  remarkable  mental  features, 
consisting  o^  fixed  ideas;  morbid  impulses,  as  an  irresistible 
impulse  to  touch  certain  things  (delire  du  toucher);  morbid 


332  GENERAL  AND  FUNCTIONAL  DISEASES. 

fears,  as  the  dread  of  walking  in  an  open  space  (agorophobia)  ; 
dread  of  defilement  (mysophobia) ;  the  insanity  of  doubt,  in 
whicli  the  patient  is  never  certain  tliat  he  has  performed  an 
action  correctly  and  demands  the  reason  for  the  performance  of 
the  simplest  acts  ;  an  irresistible  tendency  to  repeat  continually 
certain  words  (onomatomania) ;  and  a  similar  impulse  to  count 
a  certain  number  of  times  before  performing  any  action  (arith- 
momania). 

Tic  convulsif — diagnosis,  prognosis,  treatment:  The  mental 
symptoms  distinguish  the  disease  from  simple  forms  of  tic 
and  habit-chorea.  The  disease  is  usually  incurable.  Accord- 
ing to  Osier,  recovery  may  rarely  occur.  The  freahnent  con- 
sists of  isolation,  tonics,  antispasmodics. 

OTHER  AFFECTIONS  DESCRIBED  AS  CHOREA. 

Saltatory  spasm :  Under  this  title,  and  also  as  latah, 
rayriachit,  and  jumpers,  has  been  described  an  affection  in 
Mdiich,  only  when  the  patient  attempts  to  stand,  there  are 
strong  contractions  of  the  leg-muscles,  which  cause  a  jump- 
ing or  springing  motion.  It  is  more  frequent  in  men,  and 
the  subjects  are  markedly  neurotic.  It  may  be  transitory  or 
persist  for  years.  It  sometimes  occurs  as  an  endemic  neuro- 
sis, especially  in  Maine  and  Canada,  there  known  as  jump- 
ers ;  in  parts  of  Russia,  knowo  as  myriachit ;  and  Java, 
known  as  latah.  Echolalia  and  echokinesia  are  often  present 
in  these  cases. 

Paramyoclonus  Multiplex. 

Synonyms — definition :  This  disease,  also  known  as  myo- 
clonus multiplex,  convulsive  tremor,  myospasm,  is  rare.  It 
is  characterized  by  quick,  clonic,  spasmodic  contractions  of  the 
muscles  of  the  trunk  and  extremities,  occurring  usually  in 
neurasthenic  or  hysterical  subjects. 

Etiology  :  Frights,  shock,  muscular  over-exertion,  and  men- 
tal strain  may  excite  attacks. 

The  symptoms  are  :  Bilateral  spasms,  involving  the  same 
muscles  on  both  sides,  and  occurring  only  at  intervals ;  as 
much  as  a  week  may  intervene.     The  muscles  most  involved 


EPILEPSY.  333 

are  those  of  the  trunk  and  ujjper  part  of  the  limbs.  The 
diaphragm  is  also  sometimes  affected.  The  tendon-  and  skin- 
reflexes  are  increased.  There  are  no  disturbances  of  sensa- 
tion and  no  mental  disorder.  The  spasms  begin  usually  in 
the  shoulder  and  arms,  and  are  nxpid  and  violent,  varying 
from  5  to  180  per  minute.  Tapping  the  tendons  or  irritating 
the  skin  may  bring  on  an  attack  ;  emotional  excitement  also 
may  have  a  similar  effect. 

The  prognosis  is  usually  favorable.  Often  it  lasts  but  a 
few  months.     Rarely  it  is  fatal. 

Treatment  consists  of  antisj^asmodics,  attention  to  the  gen- 
eral health,  and  the  administration  of  tonics,  such  as  iron  and 
arsenic ;  static  electricity  and  galvanism,  the  latter  applied 
by  passing  strong  currents  down  the  spine. 

Post-hemiplegic  chorea  and  athetoid  movements  are  described 
on  p.  36,  and  hysterical  chorea  on  p.  361. 

EPILEPSY. 

Definition — varieties :  An  affection  of  the  brain  character- 
ized usually  by  paroxysmal  attacks  of  unconsciousness,  with 
or  without  convulsions,  more  rarely  by  convulsions  without 
loss  of  consciousness.  The  loss  of  consciousness  with  con- 
vulsive seizure  is  known  as  grand  mcd ;  transient  loss  of 
consciousness  without  convulsion,  as  j^etif  mal ;  localized  con- 
vulsions without  loss  of  consciousness  are  sometimes  the 
manifestation  of  Jacksonian  epilepsy. 

Etiology  :  A  large  proportion  of  the  cases  begin  before  the 
age  of  puberty.  Of  1450  cases  analyzed  by  Gowers,  422 
developed  the  disease  before  the  tenth  year,  and  75  per  cent, 
began  before  the  twentieth  year.  Most  of  these  cases  are  of 
the  so-called  idiopathic  form,  in  which  no  cause  can  be  deter- 
mined. Others  are  due  to  organic  brain  disease,  especially 
causes  producing  cerebral  palsies  of  children  (see  p.  200). 
Patients  developing  the  idiopathic  form  often  are  children  of 
neurotic  families,  those  in  whom  neuralgia,  hysteria,  and 
insanity  prevail.  Chronic  alcoholism  and  syphilis,  jiarticu- 
larly  the  former,  in  the  jmrents  may  also  act  as  predisposing 
causes.     Rhachitic   children   are  probably  also  predisposed. 


334  GENERAL  AND  FUNCTIONAL  DISEASES. 

Trauma,  exclusive  of  that  causing  visible  brain  injury,  some 
reflex  irritation,  as  worms,  teething,  indigestible  food,  adhe- 
rent prepuce  or  nasal  disease,  may  act  as  exciting  causes  in 
those  predisposed.  Infectious  fevers  may  also  act  in  the 
same   way. 

Epilepsy  developing  in  persons  past  thirty  is  probably 
never  idiopathic,  and  may  be  due  to  one  of  the  following 
causes  :  Organie  brain  disease,  as  tumor,  abscess,  syphilis, 
traumatism  causing  fracture  of  the  skull. 

Toxcmiias,  notably  alcohol,  lead,  urtemia,  diabetes,  syphilis 
(when  a  parasyphilitic  disorder),  products  of  intestinal  putre- 
faction— this,  while  rarely  an  exciting  cause,  certainly  aggra- 
vates the  symptoms  in  those  who  already  have  the  disease. 

Reflex  irritation:  True  reflex  epilej^sy  is  rare,  but  eye- 
strain, nasal  disease,  or  some  other  source  of  irritation  may 
now  and  then  be  the  cause  of  epileptiform  convulsions. 

Circulatory  disturbances,  due  to  weak  heart  from  any  cause ; 
disease  of  the  bloodvessels.  Of  these  causes,  syphilis  is  the 
most  frequent. 

Epilepsy — symptoms — (1)  grand  mal:  Precursory  symj^toms, 
consisting  of  one  or  more  of  the  following,  viz.,  irritability 
of  temper,  mental  changes  amounting  to  insanity,  persistent 
giddiness,  headache,  sudden  jerkings,  voracious  appetite  may 
in  rare  instances  precede  for  several  days  the  fit. 

In  about  one-half  the  cases  a  peculiar  sensation  of  move- 
ment in  some  part  of  the  body  directly  precedes  the  convul- 
sion ;  this  is  known  as  the  a^ira.     It  may  consist  of: 

(a)  Either  a  motion  or  sensation,  or  both,  in  some  part  of 
one-half  the  body,  usually  the  hand ;  if  a  sensation,  it  is  a 
numbness  or  tingling ;  if  a  motion,  it  is  usually  twitching  of 
the  fingers.  It  may  then  ascend  the  arm  to  the  head,  trunk, 
and  then  involve  the  leg  before  consciousness  is  lost.  It 
may  begin  in  the  leg,  face,  or  tongue,  and  may  pass  down 
instead  of  up  the  limb.  This  form  of  aura  is  more  frequent 
in  cases  of  focal  brain  lesion. 

(b)  Sensations  of  motion  in  both  limbs  ;  general  tremor  or 
shivering ;  sense  of  general  malaise  ;  of  heat  or  a  feeling  of 
faintness. 

(c)  Visceral  or  pneuraogastric  warnings,  consisting  of 
vague  sensations  or  pain  in  the  epigastrium,  sometimes  asso- 


EPILEPSY.  335 

ciated  with  nausea ;  i>eculiar  sensations  ascending  from  the 
epigastriura  to  the  throat  or  head,  sometimes  producing  a 
sense  of  choking ;  cardiac  palpitation  or  pain  in  that  region. 

(d)  CephaHc  sensations,  consisting  of  giddiness,  subjective 
or  objective;  turning  of  the  head  and  eyes;  headache;  som- 
nolence. 

(e)  Psychical  aurse,  consisting  of  a  certain  emotion  or  idea, 
always  the  same  in  the  same  case ;  a  feeling  as  if  something 
were  wrong. 

(/)  Special  sense  aura?  are  frequent.  If  olfactory  sensa- 
tions, they  are  usually  an  unpleasant  smell.  These  are  some- 
times due  to  organic  brain  disease  involving  the  uncinate 
gyrus.  Gustatory  sensations,  consisting  of  sour,  bitter,  or 
metallic  taste  ;  auditory,  as  sudden  loss  of  hearing,  peculiar 
sounds.  Visual  aura?  are  the  most  common  ;  they  may  be 
flashes  of  light,  hallucinations. 

(g)  Rarely  the  attack  is  preceded  by  some  coordinated 
movement,  as  running  for  some  distance  (procursive  epilepsy), 
or  whirling  about. 

Either  a  loud  cry  or  peculiar  groan  sometimes  is  given 
just  at  the  onset  of  the  attack.  As  the  convulsion  begins 
the  patient  falls,  tonic  spasm  causing  the  head  to  be  rotated 
or  drawn  backward,  and  sometimes  deviation  of  the  eyes  and 
mouth  to  the  side  most  affected  sets  in.  The  hands  are 
clenched,  the  thumb  often  being  inside  the  fingers,  and  the 
arms  flexed  at  the  elboAvs  and  the  hands  at  the  wrist,  and  the 
legs  extended.  Owing  to  the  impeding  of  the  respiration  the 
initial  pallor  gives  way  to  lividity.  The  pupils  are  usually 
dilated  and  insensitive  to  light.  The  tonic  spasm  lasts  but 
a  short  time,  and  gives  way  to  clonic  spasm,  in  which  all  the 
muscles  are  in  violent  contraction,  saliva  exudes  from  the 
mouth,  and,  if  the  tongue  is  bitten,  as  it  usually  is,  is  blood- 
stained. Urine  and  faeces  are  discharged,  and  the  cyanosis 
gradually  lessens.  This  stage  usually  lasts  two  or  three 
minutes.  After  the  contractions  lessen  the  patient  remains 
comatose,  the  face  congested,  and  the  breathing  stertorous. 
In  a  short  while  he  can  be  aroused;  but  if  left  to  himself, 
sleeps  for  some  hours.  Afterward  he  may  complain  of  head- 
ache or  mental  confusion. 

In  rare  instances  the  patient  may  remain  in  a  condition  of 


336  GENERAL  AND  FUNCTIONAL  DISEASES. 

trunee,  in  which  he  may  perform  apparently  purposive  and 
logical  actSj  but  of  which  he  has  no  recollection  afterward. 
Crimes  have  been  committed  while  in  this  state.  This  is 
known  as  epileptic  automatism,  and  may  occur  without  the 
preceding-  convulsion.  Or  he  may  become  maniacal  and 
homicidal.  8uch  attacks  may  also  occur  in  place  of  the  fit 
(see  Epileptic  Insanity).  Patients  who  have  frequent  attacks 
become  demented  sooner  or  later. 

Transient  paralysis,  often  hemiplegic  in  type,  or  aphasia 
may  follow  an  attack.  Very  rarely  such  paralysis  may  occur 
in  place  of  the  convulsion.  Attacks  may  occur  at  night 
during  sleep  ;  in  some  patients  they  only  occur  then.  Occa- 
sional incontinence  of  urine  at  night,  waking  in  the  morning 
with  headache,  and  mental  confusion  are  suggestive  of  noctur- 
nal epilepsy. 

If  a  number  of  attacks  follow  each  other  in  rapid  succes- 
sion, the  condition  is  termed  the  status  epilepticus.  In  this 
the  temperature  may  rise,  and  after  the  convulsions  cease  the 
patient  becomes  greatly  prostrated  and  delirious. 

(2)  Petit  mal :  These  attacks  consist  of  transient  uncon- 
sciousness, sometimes  accompanied  with  a  feeling  of  giddiness 
or  faintness.  They  are  of  very  brief  duration.  Usually  the 
patient  M'ill  be  noticed  suddenly  to  stop  whatever  he  is  doing. 
In  some  cases  the  eyes  become  fixed  and  the  face  slightly 
pale ;  in  others  there  is  no  change  of  color.  If  anything  is 
in  the  hand  at  the  time,  it  is  usually  dropped.  In  a  second 
or  two  the  attack  passes  off  and  the  patient  resumes  what  he 
had  been  doing,  as  if  nothing  had  happened.  The  attack  may 
be  preceded  by  a  warning  sensation,  and  in  many  patients 
this  is  the  only  thing  which  enables  them  to  know  that  they 
have  had  a  seizure,  as  the  period  of  unconsciousness  is  so 
momentary  that  they  are  unaware  of  it.  Gowers  mentions 
the  following  as  the  chief  characteristics  of  petit  mal,  arranged 
in  the  order  of  frequency  : 

1.  Sudden  momentary  unconsciousness,  or  "fainting,"  or 
"  sleepiness,"  without  Avarning. 

2.  Giddiness. 

3.  Jerks  or  starts  of  the  limbs,  trunk,  or  head. 

4.  Visual  sensations  or  loss. 

5.  Mental  state  :  sudden  sense  of  fear,  etc. 


EPILEPSY.  337 

6.  Unilateral  peripheral  sensation  or  spasm. 

7.  Epigastric  sensation. 

8.  Sudden  tremor. 

9.  Sensations  in  both  hands. 

10.  Pain  or  other  sensation  in  the  head. 

11.  Choking  sensation  in  the  throat. 

12.  Sudden  scream. 

13.  Olfactory  sensation. 

14.  Cardiac  sensation. 

15.  Sensation  in  nose  or  eyeball. 

16.  Sudden  dyspnoea. 

17.  General  "indescribable"  sensations. 

After  these  attacks  patients  may  perform  automatic  actions, 
as  after  attacks  of  grand  mal. 

Convulsions  usually  sooner  or  later  develop,  and  the  two 
forms  often  coexist. 

Jacksonian  epilepsy :  These  attacks  are  usually  the  result 
of  irritative  lesions  affecting  the  motor  region  of  the  cortex ; 
but  may  be  caused  by  either  uraemia  or  paretic  dementia. 
They  are  peculiar  in  that  consciousness  is  either  not  lost  at  all 
or  is  lost  late.  In  a  typical  attack  there  is  usually  a  feeling 
of  tingling  or  numbness,  succeeded  by  spasm  in  a  limited 
group  of  muscles  of  the  face,  arm,  or  leg.  For  instance,  the 
mouth  may  be  drawn  to  one  side  or  a  finger  twitch.  The 
muscles  first  affected  indicate  the  seat  of  the  lesion.  The 
spasm  then  spreads  to  adjacent  centres  and  gradually  involves 
all  the  muscles  of  the  limb  or  face,  without  loss  of  conscious- 
ness. In  more  severe  attacks  the  spasm  finally  involves  the 
entire  side,  and  then  becomes  general,  with  loss  of  conscious- 
ness. 

Epilepsy — morltid  anatomy  and  pathology  :  Except  when  due 
to  organic  brain-disease,  no  constant  changes  have  been  yet 
discovered  in  the  brain  of  epileptics.  All  we  know  is  that  it 
is  a  disease  of  the  cortex. 

Diagnosis :  Attacks  of  petit  mal  may  have  to  be  distin- 
guished from  syncope  and  vertigo.  From  syncope  the  dis- 
tinction rests  upon  the  absence  of  obvious  cause,  the  sudden- 
ness of  the  onset  and  return  to  the  normal  condition,  the 
absence  of  weakness  of  the  pulse,  and  a  history  of  frequent 

22— N.  D. 


338 


GENERAL  AND  FUNCTIONAL  DISEASES. 


previous  attacks.  Vertigo  is  rarely  attended  by  unconscious- 
ness ;  the  giddiness  lasts  longer,  and  the  return  to  normal  is 
more  gradual.  In  Meniere's  disease  evidences  of  disease  of 
the  internal  ear  will  be  present  (see  Aural  Vertigo). 

When  the  attack  consists  of  convulsive  seizures,  it  is  neces- 
sary to  distinguish  them  from  those  due  to  hysteria.  The 
following,  from  Gowers,  illustrates  the  differences  between 
them  : 


Epilepsy. 

Hysteeia. 

Apparent  cause    .  .   . 

None. 

Emotion. 

Warning 

Any,  but  especially  unilateral 

Palpitation,  malaise,  choking, 

or  epigastric  aurse. 

bilateral  foot  aurae. 

Onset 

Always  sudden. 

Often  gradual. 

Scream 

At  onset. 

During  course. 

Convulsion     

Rigidity,    followed    bv 

jerk- 

Rigidity      or     "  struggling," 

ing,  rarely  rigidity  alone. 

throwing  about  of  limbs  or 

head,  arching  of  the  back. 

Biting 

Tongue. 

Lips,  hands,  other  people  or 
things. 

Never. 

Micturition 

Frequent. 

Defecation 

Occasional. 

Never. 

Talking 

Never. 

Frequent. 

Duration 

A  few  minutes. 

More  than  ten  minutes,  often 
longer. 

Restraint  necessary    . 

To  prevent  accident. 

To  control  violence. 

Termination 

Spontaneous. 

Spontaneous      or       induced 
(water,  etc.). 

Also  in  the  epileptic  convulsion  there  is  absence  of  the 
pupillary  reflex ;  in  hysteria  this  is  present.  The  initial 
pallor  which  precedes  the  facial  lividity  is  peculiar  to  epi- 
lepsy. As  this  period  is  very  brief,  close  observation  may  be 
required  in  order  to  detect  it. 

It  should  be  remembered  that  hysteria  may  occur  in  epi- 
leptics. 

Having  determined  that  the  attacks  are  epileptic,  it  is 
necessary  to  determine  whether  they  are  idiopathic  or  due  to 
some  of  the  ascertainable  causes  mentioned.  Attacks  occur- 
ring for  the  first  time  in  a  person  over  thirty  years  are  prac- 
tically never  idiopathic.  In  this  connection  it  must  be 
remembered  that  long  remissions  may  occur,  and  careful  in- 
quiry must  be  made  to  be  sure  that  the  attack  is  actually  the 
first.  If  it  is  so,  then  careful  search  must  be  made  for  the 
existence  of  the  causes  mentioned. 


EPILEPSY.  339 

In  Jacksonian  epilepsy  the  cause,  whether  tumor ;  lesions 
causing  infantile  cerebral  palsies ;  localized  meningo-enceph- 
alitis ;  abscess ;  ursemiaj  or  paretic  dementia,  must  be  deter- 
mined. 

Epilepsy — prognosis :  Death  rarely  occurs  during  a  fit. 
The  status  epilepticus  often  causes  death  by  exhaustion. 

It  is  probable  that  a  small  percentage  of  cases  recover ;  and 
this  result  is  most  likely  to  be  attained  in  those  cases  in 
which  the  fits  are  not  frequent  and  active  treatment  is  com- 
menced early  and  continued.  But  it  is  impossible  to  predict 
recovery  in  any  case.  It  must  also  be  remembered  that  long 
remissions  (twenty-nine  years  in  a  case  mentioned  by  Sinkler) 
may  take  place. 

In  organic  epilepsy,  if  due  to  syphilis,  the  prognosis  is  fair. 
When  due  to  tumor,  a  certain  number  may  be  cured  if  oper- 
ated upon  early.  If  the  spells  have  lasted  two  years,  opera- 
tion is  of  no  service. 

Epilepsy — treatment :  A  child  who  develops  convulsions 
from  any  cause  should  be  treated  carefully  for  some  time 
after ;  for  in  a  predisposed  child  a  convulsion  due  to  some 
peripheral  irritation  may  be  the  starting-point  of  future 
epilepsy.  Hence  all  sources  of  irritation  should  be  removed ; 
the  child  put  under  the  best  possible  hygienic  conditions,  and 
small  continued  doses  of  antispasmodics  given.  During  an 
epileptic  convulsion  no  special  treatment  is  necessary  ;  the 
clothing  may  be  loosened,  and  something  placed  between  the 
teeth.  Epileptics  should  have  an  easily  digested  diet,  meat 
being  allowed  but  once  a  day.  Overloading  of  the  stomach 
should  be  avoided.  Some  fixed  employment  is  beneficial. 
Excitement  of  any  kind  should  be  avoided. 

Colonization  of  a  large  number  of  epileptics,  where  they 
can  have  the  benefit  of  country  air,  out-door  employment, 
and  education,  has  proved  of  much  value. 

To  influence  the  seizures  the  bromides,  preferably  ammo- 
nium or  strontium,  are  the  most  useful ;  their  effects  are 
usually  increased  by  the  addition  of  antipyrin,  as  recom- 
mended by  H.  C.  Wood.  For  an  adult  twenty  or  thirty 
grains  of  the  bromides  and  five  or  six  grains  of  antipyrin  may 
be  given  three  or  four  times  daily,  according  to  the  effect  de- 
sired.    Atropine,   alone   or  combined  with  a  bromine  salt, 


340  GENERAL  AND  FUNCTIONAL  DISEASES. 

may  also  prove  of  service.  Some  cases  do  not  appear  to  be 
benefited  by  the  bromides ;  in  fact,  the  symptoms  may  be 
aggravated ;  in  such,  or  when  decided  symptoms  of  bromism 
occur,  the  fluid  extract  of  Solanum  caroHnense,  in  dose  of 
forty  drops  to  a  teaspoonful,  t.  i.  d.  for  an  adult,  may  be  tried. 
Borax  (gr.  x-xx  t.  i.  d.)  has  been  recommended.  Ipecac  has 
been  recently  recommended,  the  commencing  dose  being  ten 
minims  of  the  wine,  increased  to  forty,  three  times  daily.  If 
the  heart  is  weak,  cardiac  tonics  (except  strychnine)  should 
be  given.  Nitroglycerin  may  be  of  service,  especially  if  there 
is  arterio-sclerosis.  In  obstinate  cases  Flechsig's  treatment 
is  often  serviceable.  It  consists  in  giving  opium  in  doses  of 
gr.  l  t.  i.  d.,  increased  to  gr.  iij  or  v  t.  i.  d.  This  is  con- 
tinued for  five  or  six  weeks.  The  patient  is  then  placed  on 
large  doses  of  the  bromides.  In  addition  to  these  measures, 
the  general  health  must  be  maintained  by  arsenic  and  other 
tonics,  and  the  digestive  organs  kept  in  good  condition  by 
means  of  laxatives  and  intestinal  antiseptics,  and  all  sources  of 
peripheral  irritation  removed.  In  Jacksonian  epilepsy  the 
question  of  the  advisability  of  a  surgical  operation  may  be 
raised.  This  is  justifiable  under  the  following  conditions, 
viz.  •}  If  not  more  than  two  years  have  elapsed  since  the  trau- 
matism or  beginning  of  the  disease  which  causes  the  seizures. 
If  there  is  a  depression  of  the  skull,  operation  is  warranted 
at  any  period.  In  focal  epilepsy  without  visible  lesion  ex- 
cision of  the  centres  is  justifiable  if  the  symptoms  have  lasted 
but  a  short  time.  When  the  status  epilepticus  occurs  chloral 
and  hypodermatic  injections  of  morphine  should  be  tried. 
In  Jacksonian  epilepsy  a  tight  band  applied  about  the  limb 
when  a  seizure  is  felt  approaching  will  often  arrest  it. 

NEURASTHENIA. 

Synonyms — definition :  This  affection  is  commonly  known 
among  the  laity  as  either  nervous  prostration,  nervous  de- 
bility, or  nervous  exhaustion.  It  is  a  condition  in  which 
there  is  more  or  less  marked  and  persistent  diminution  of 
nervous  energy,  together  with  an  increased  reaction,  mental 

*  Condensed  from  conclusions  reached  by  Sachs  and  Gerster,  in  Araer. 
Jour.  Med.  Sci.,  vol.  cxii.  p.  392, 


NEURASTHENIA.  341 

and  physical,  to  external  impressions.  In  other  words,  we 
have  two  principal  symptoms,  nervous  weakness  and  nervous 
irritability.     (Dercum.) 

Etiology :  Neurasthenic  parents,  or  those  who  are  alcoholic, 
tubercular  or  syphilitic,  are  predisposing  causes.  Children 
begotten  by  parents  who  are  old  are  also  apt  to  become  neu- 
rasthenic. The  overworking,  either  mental  or  physical,  of 
children  may  lay  the  foundation  for  future  neurasthenia. 

The  exciting  causes  are  overwork,  either  mental  or  physi- 
cal ;  alcoholic  and  sexual  excesses ;  sexual  abstinence ;  pro- 
longed physical  or  mental  strain  ;  excessive  childbearing  and 
prolonged  lactation;  infectious  diseases,  especially  influenza; 
physical  injury  and  emotional  shock  ;  excessive  use  of  tea, 
coffee,  and  tobacco  ;  auto-intoxication  due  to  the  absorption 
of  the  products  of  intestinal  putrefaction,  as  would  occur  in 
chronic  constipation  and  gastro-intestinal  indigestion.  It  may 
also  accompany  other  chronic  and  exhausting  diseases,  as 
tuberculosis,  aneemia,  chlorosis,  diseases  of  the  sexual  organs, 
etc.,  and  be  associated  with  hypochondriasis  and  hysteria. 

Symptomatology. 

Symptoms  :  Patients  with  neurasthenia  describe  their  con- 
dition as  follows  :  They  "  are  nervous,"  they  get  easily  ex- 
cited and  irritated,  they  cannot  do  as  much  physical  work  as 
they  formerly  did,  and  in  attempting  any  mental  effort  they 
become  confused  and  are  unable  to  concentrate  their  atten- 
tion. They  will  also  complain  of  insomnia,  depression  of 
spirits,  indigestion,  and  palpitation  of  the  heart.  In  some, 
most  of  the  complaint  is  about  the  sexual  organs,  of  excessive 
nightly  emissions,  loss  of  sexual  power,  etc.  When  carefully 
examined,  such  patients  will  be  found  to  present  motor, 
sensory,  psychic,  and  somatic  symptoms. 

Motor  symptoms  :  In  the  majority  of  cases  there  will  be 
general  muscular  weakness  ;  he  cannot  walk  as  far  as  for- 
merly ;  in  fact,  tires  sooner  after  any  physical  exertion.  For 
a  few  moments  he  may  be  able  to  exert  his  usual  strength, 
but  it  soon  becomes  exhausted.  A  common  symptom  is  fine 
tremor,  generally  but  not  always  limited  to  the  hands  and 
tongue    and    increased    by    exertion.       Fibrillary    muscular 


342  GENERAL  AND  FUNCTIONAL  DISEASES. 

tremors  and  spasms  of  the  muscles  may  also  be  observed. 
The  knee-jerks  are  usually  increased,  but  this  differs  from  that 
due  to  organic  cause  iu  the  fact  that,  if  tested  repeatedly,  they 
soon  become  exhausted  and  hence  diminished.  Instead  of 
this,  they  may  be  normal,  lessened  or  absent,  in  which  case 
they  can  be  elicited  by  reinforcement  (see  p.  52).  The  tendon- 
reactions  in  the  arms  may  also  be  increased.  The  tendon- 
reactions  may  vary,  being  present  at  one  time  and  absent 
at  another. 

Sensory  symptoms :  These  may  consist  of  a  feeling  of  ma- 
laise and  a  constant  feeling  of  tire  and  exhaustion.  A  feel- 
ing of  tightness  about,  or  pressure  upon,  various  parts  of  the 
body  often  exists.  More  or  less  pronounced  vertigo  is  a  fre- 
quent symptom.  It  is  usually  paroxysmal,  following  exer- 
tion ;  but  may  be  constant.  Dull  j^ains  and  aches  in  various 
parts  of  the  body,  especially  the  head,  back,  and  legs,  are 
complained  of.  AVith  the  headache  of  neurasthenia  there  is 
often  a  feeling  of  constriction,  as  if  a  tight  band  were  about 
the  head,  or  there  is  a  sense  of  pressure  upon  the  top  of  the 
head. 

Backache  is  usually  referred  to  the  small  of  the  back, 
although  often  there  may  be  burning  sensations  in  the  scapu- 
lar region.  Along  with  the  pain  there  are  often  found  areas 
of  great  tenderness  along  the  spine.  They  are  elicited  by 
light  pressure ;  may  change  their  location  from  time  to  time, 
but  are  most  commonly  located  over  the  seventh  cervical 
vertebra,  the  mid-dorsal  region,  the  dorso-lumbar  junction, 
the  mid-lumbar  region,  and  over  the  sacrum  and  coccyx. 
These  areas  may  exist  without  spontaneous  pain  being  pres- 
ent. This  symptom  has  been  sometimes  incorrectly  termed 
"  spinal  irritation." 

There  may  be  cutaneous  hypersesthesia  in  various  regions 
and  parsesthetic  sensations  as  numbness,  tinglings,  sensations 
of  heat  or  cold,  etc. 

The  special  senses  may  also  suffer  :  the  eyes  soon  tire,  brief 
use  for  reading  or  other  fine  work  causing  blurring,  confu- 
sion, headache,  and  vertigo.  The  visual  fields  may  be  slightly 
contracted.  More  rarely  there  is  retinal  hypersesthesia.  The 
ocular  muscles  may  become  weak  in  common  with  the  other 
muscles  of  the  body,  and  muscular  insufficiencies  and  impair- 


NEURASTHENIA.  343 

ment  of  accommodation  may  be  present.  Patients  may  also 
complain  of  objects  appearing  misty  or  of  specks  floating  in 
front  of  the  eyes  (muscse  volitantes). 

Various  forms  of  tinnitus  aurium  are  often  present,  and 
hyperEesthesia  of  the  auditory  nerve  may  be  the  means  of 
causing  patients  to  suffer  much  from  slight  noises. 

Taste  may  be  impaired  or  disagreeable  tastes  may  be  com- 
plained of.  1-1 

Psychic  symptoms :  The  ability  to  sustain  prolonged  mtel- 
lectual  effort  is  interfered  with.  If  attempted,  in  a  short 
time  confusion,  lack  of  concentration,  headache,  and  vertigo 
appear.  Such  patients  will  complain  that  they  are  "  losing 
their  mind  "  or  "  their  memory."  Investigation  will  show, 
however,  that  their  memory  is  good.  There  is  disinclination 
to  think  or  try  to  perform  mental  labor,  and  self-confidence 
is  lost.  There  is  usually  marked  irritability  of  temper,  and 
often  loss  of  affection  for  those  formerly  held  dear.  The 
patient  may  be  also  excessively  emotional. 

Neurasthenics  become  introspective ;  they  are  continually 
watching  for  new  symptoms  and  dwelling  upon  and  conse- 
quently unconsciously  exaggerating  the  old,  and  attaching 
undue  importance  to  them. 

Causeless  fear  is  frequently  suffered  from;  there  is  dread 
of  some  impending  danger  either  to  the  patient  himself  or 
his  relatives  ;  or  there  may  be  attacks  of  sudden  fear,  for 
which  no  cause,  even  imaginary,  can  be  given.  Some  of  the 
various  forms  of  morbid  fear,  such  as  fear  of  open  spaces 
(agarophobia) ;  fear  of  closed  places  (claustrophobia) ;  of  being 
alone  (monophobia) ;  of  crowds  ;  of  storms,  or  of  darkness 
are  frequently  present,  as  may  be  also  the  mania  of  doubt 
(tic  convulsif ).  Insomnia  is  an  early  and  frequent  symptom  ; 
the  sleep  may  be  restless  or  the  patient  falls  asleep  normally, 
but  awakens  much  sooner  than  he  should.  Sleep  is  not  re- 
freshing, and  the  patient  complains  of  feeling  more  tired  in 
the  morning  than  when  he  retired.  Horrible  dreams  may  be 
complained  of. 

Somatic  symptoms  :  These  consist  of  disturbances  of  diges- 
tion, of  circulation,  of  secretion,  and  of  the  sexual  functions. 
Digestive  disturbances  are  very  common  ;  while,  as  has  been 
mentioned  under  etiology,  they  may  cause  neurasthenia,  it 


344  GENERAL  AND  FUNCTIONAL  DISEASES. 

is  also  true  that  in  some  cases  they  are  caused  by  it.  They 
are  usually  manifested  by  feelings  of  heaviness  and  discom- 
fort in  the  epigastrium,  appearing  a  great  or  less  length  of 
time  after  eating.  In  more  aggravated  cases,  acid  eructations 
(heartburn),  flatulence,  nausea,  and  even  vomiting  may  be 
present.  The  tongue  may  be  coated,  but  more  commonly  is 
clean,  but  flabby  and  marked  with  the  teeth.  Constipation  is 
the  rule.  In  some  cases  the  appetite  is  increased,  but  food 
does  not  satisfy  hunger. 

The  most  common  circulatory  disturbance  is  palpitation  of 
the  heart.  It  is  often  associated  with  the  gastro-intestinal 
disturbances  mentioned  above.  There  may  be  sensations 
of  pain  in  the  cardiac  region  during  these  attacks,  and  they 
may  resemble  angina  pectoris.  Instead  of  palpitation,  the 
pulse-rate  may  be  permanently  increased.  Vasomotor  symp- 
toms are  common.  A  frequent  one  is  aortic  pulsation,  caus- 
ing a  deep-seated  throbbing  in  the  epigastrium.  It  may  be 
often  felt  by  the  hand.  Flushings  of  the  face  and  other  parts 
and  coldness  and  lividity  of  the  extremities  are  also  frequent. 

There  may  be  lessening  of  all  the  secretions — viz.,  urine, 
saliva,  perspiration,  etc. — or  they  may  be  increased,  especially 
the  perspiration.  This  increase  may  be  only  noticed  at  nights, 
Avhen  nightsweats  occur.  Even  when  the  actual  quantity  of 
urine  is  not  increased,  frequent  urination  is  a  common  symp- 
tom. The  urine  often  contains  an  excess  of  uric  acid  and 
urates,  of  phosphates  or  of  oxalates.  Phosphatic  urine  is 
cloudy  while  being  passed,  and  such  ]>atients  often  imagine 
that  they  have  spermatorrhoea. 

Sexual:  In  some  cases  these  may  dominate  the  picture  of 
the  disease,  such  cases  being  often  termed  sexual  neurasthenia. 
In  others  they  are  secondary  to  other  symptoms.  In  men 
they  consist  of  frequent  nightly  emissions,  of  premature 
ejaculation  when  sexual  intercourse  is  attempted,  incomplete 
erections,  absence  of  pleasurable  sensation,  and  various  par- 
sesthesias  referred  to  the  genital  organs.  Spermatorrhoea  is 
imagined,  especially  if  the  urine  is  phosphatic  or  there  is  a 
discharge  of  prostatic  secretion,  which  often  occurs.  Women 
may  also  suffer  from  involuntary  orgasms  at  night  and  sexual 
weakness.  They  are  apt  to  have  pains  in  the  pelvic  region, 
and   possibly  ovarian   tenderness   loithout   the   existence   of 


NEURASTHENIA.  345 

organic  disease  of  the  orr/ans.  Jt  must  he  understood  that 
all  of  the  symptoms  detailed  do  not  oceur  in  every  ease.  Also 
tliat  while  neurasthenia  is  a  disease  of  the  general  nervous 
system,  one  part  may  be  aflPeetcd  more  than  another ;  in  one, 
cord  symptoms  predominate,  in  another  cerebral. 

Neurasthenia — pathology  :  In  the  light  of  our  present  knowl- 
edge, neurasthenia  is  a  functional  disease.  C.  F.  Hodge  has 
shown  that  in  cells  fatigued  by  constant  work  the  nucleus 
decreases  in  size,  becomes  irregular  in  outline,  loses  its  reticu- 
lated appearance,  stains  darker,  and  that  the  cell-protoplasm 
shrinks  slightly  in  size  and  stains  more  feebly.  It  is  pos- 
sible that  in  persons  who  for  a  long  time  overwork  their 
nerve-cells  or  expose  them  to  any  of  the  influences  men- 
tioned under  etiology  they  lose  their  power  of  recovery,  and 
these  changes  remain  permanent.  Traumatic  neurasthenia 
will  be  considered  in  another  place.  When  a  person  has  suf- 
fered from  neurasthenia  for  a  long  time  certain  permanent 
changes  in  the  organs  may  occur — viz.,  catarrh  of  the  stomach 
and  intestines,  aneemia,  and  arterial  degeneration. 

Neurasthenia — diagnosis  :  It  is  important  to  remember  that 
in  rare  instances  cerebral  growths,  especially  those  involving 
the  frontal  lobes,  may  for  a  long  time  present  none  but  symp- 
toms resembling  those  of  neurasthenia.  Also  the  grave  or- 
ganic diseases  of  other  organs  may  so  begin — viz.,  tuberculo- 
sis, diseases  of  the  blood,  gastric  cancer,  dilated  stomach, 
chronic  uterine  or  ovarian  disease.  Careful  examination 
should  be  made  to  detect  the  presence  of  any  of  these  disor- 
ders. Simple  neurasthenia  must  be  difPerentiated  from  hys- 
teria, hypochondria,  exophthalmic  goitre,  melancholia,  and 
the  commencement  of  paretic  dementia. 

Hysteria  major  is  distinguished  by  convulsions,  areas  of 
anaesthesia,  reversal  of  the  color-fields,  various  forms  of 
paralysis  and  contractures.  In  hysteria  of  a  milder  type 
these  may  be  absent,  but  the  onset  of  the  symptoms  is  apt  to 
be  sudden  ;  they  vary  from  day  to  day,  insomnia  is  not  com- 
mon ;  headache,"^  if  present,  is  of  the  peculiar  type  known  as 
hysterical  clavus  ;  globus  hystericus  will  probably  be  coni- 
plained  of;  there  maybe  intervals  in  which  the  health  is 
good.     It  must  be  remembered  the  neurasthenia  may  be  a 


346  GENERAL  AND  FUNCTIONAL  DISEASES. 

predisposing   cause  of  hysteria,  hence   symptoms  of  the   two 
may  coexist. 

Although  hypociiondriacs  may  complain  of  various  symp- 
toms, examination  will  show  tiiat  the  organs  complained  of 
are  in  good  condition,  and  that  their  functions  are  performed 
properly.  Here  again,  however,  a  neurasthenic  may  become 
hypochondriacal. 

The  presence  of  exophthalmos,  enlarged  thyroid,  and  ex- 
treme tachycardia  distinguishes  exophthalmic  goitre.  In 
cases  where  these  symptoms  are  not  marked,  the  diagnosis 
may  be  doubtful. 

The  early  stages  of  melancholia  may  simulate  neurasthenia, 
but  differs  in  the  more  marked  depression,  more  marked  in- 
somnia, refusal  to  eat,  and  possibly  the  presence  of  delusions 
and  suicidal  impulses. 

The  early  stages  of  paretic  doiientia  are  also  characterized 
by  neurasthenic  sym])toms,  but  the  loss  of  memory,  tremor 
of  the  facial  muscles  and  tongue,  unequal  and  Argyll-Robert- 
son pupil,  and  a  feeling  of  well-being,  will  distinguish  that 
disease. 

Prognosis :  Neurasthenia  is  a  chronic  disease,  and  may  last 
for  years  with  intervals  of  improvement.  Recovery  may  oc- 
cur, but  any  undue  strain  is  apt  to  produce  a  relapse. 

Neurasthenia — treatment :  Cases  of  general  neurasthenia 
are  best  treated  by  the  so-called  "Rest  Treatment"  (see  p. 
76).  If  the  case  is  mild,  this  need  not  be  carried  out  abso- 
lutely;  but  can  be  modified  so  that  the  hours  of  rest  are  pro- 
longed, while  those  of  work  are  curtailed.  If  the  symptoms 
are  principally  cerebral,  motor  weakness  not  being  a  factor, 
an  out-door  life,  such  as  can  be  secured  from  a  gunning  trip, 
or  a  sea  voyage,  or  a  trip  to  the  seashore,  will  often  cause  the 
desired  result.  Or  if  this  cannot  be  obtained,  a  certain  amount 
of  regulated  out-door  exercise,  as  bicycle  or  horseback  riding, 
or  golf,  with  lengthened  hours  of  rest  and  regulation  of  diet 
may  be  sufficient.  Cold  douches  to  the  spine,  followed  by 
vigorous  friction  with  a  coarse  towel  is  an  excellent  tonic ; 
but  care  must  be  taken  not  to  begin  with  too  low  a  tempera- 
ture. This  is  especially  valuable  tor  the  relief  of  the  tender 
spine.  Warm  baths  (95°  F.)  at  night,  or  wet  packs,  are  often 
useful  to  promote  sleep  and  relieve  irritability  and  restless- 


HYSTERIA.  347 

* 
ness.  It  is  well  also  to  advise  the  use  of  considerable  quan- 
tities of  pure  water  internally.  The  bromides  may  be  used 
to  allay  the  irritability,  but  should  not  be  used  continuously. 
The  writer  has  gotten  good  results  from  a  combination  of 
bromide  and  arsenic.  Antipyrin  or  phenacetin  are  also  use- 
ful for  this  purpose,  as  is  also  yalerian.  The  condition  of  the 
alimentary  canal  must  be  looked  after.  A  diet  of  milk,  eggs, 
fish,  green  vegetables,  and  fruits,  and  but  little  meat,  being 
most  suitable.  Constipation  must  be  relieved.  Intestinal 
antiseptics  are  often  useful. 

Of  drugs  to  build  up  the  nervous  system  nux  vomica, 
mineral  acids,  arsenic,  iron,  phosphorus,  or  the  glycero- 
phosphates are  all  of  service.  The  writer  gets  good  results 
from  a  mixture  of  strychnine,  arsenic,  dilute  hydrochloric 
acid,  glycerin,  and  a  bitter  tincture,  with  bromide  of  stron- 
tium at  night  or  whenever  the  patient  becomes  irritable 
or  nervous.  The  use  of  alcohol,  tea,  coffee,  and  tobacco 
must  be  prohibited  or  restricted.  The  use  of  the  drugs 
mentioned  above  may  be  combined  with  the  rest  treatment ; 
but  as  that  plan  is  expensive,  it  is  not  available  for  many,  and 
reliance  must  be  placed  upon  hydrotherapy,  hygienic  meas- 
ures, and  drugs. 

For  the  symptoms  referred  to  the  male  sexual  organs  the 
use  of  large-sized  cold  sounds,  combined  with  measures  de- 
scribed above,  is  often  useful.  In  aggravated  cases  the 
local  application  of  silver  nitrate  to  the  prostatic  urethra 
may  be  required.  These  cases  often  are  best  treated  by  a 
genito-urinary  surgeon. 

HYSTERIA. 

Definition :  Hysteria  is  a  psycho-neurosis  due  to  disturbance 
of  the  cortical  centres  of  the  brain ;  and  characterized  by 
various  symptoms  of  an  emotional,  irritative,  and  paralytic 
nature.  It  is  a  definite  disease,  and  not,  as  is  supposed  by 
many,  due  to  simulation  and  mendacity. 

Etiology:  Heredity  is  the  great  predisposing  cause  of  the 
disease  ;  there  is  in  most  cases — but  there  are  exceptions — a 
history  of  hysteria  or  of  epilepsy,  insanity,  or  similar  neu- 
rosis in  the  parents. 


348  GENERAL  AND  FUNCTIONAL  DISEASES. 

The  e.i'cUlng  causes  are  trauma,  especially  if  accompanied 
by  fright  (see  Traumatic  Neuroses) ;  acute  and  chronic  dis- 
ease;  emotions  and  moral  shock,  as  fright,  disappointment, 
grief,  religious  excitement ;  defective  education — i.  e.,  in 
children  the  permission  of  habits  of  self-indulgence,  absence 
of  discipline,  overwork  at  school ;  toxaemia,  thus  alcohol, 
lead,  mercury,  morphine,  and  tobacco  may  excite  hysteria  ; 
and  imitation  (one  case  of  severe  hysteria  brought  in  constant 
contact  with  those  predisposed  may  excite  the  disease  in 
them).  Hysteria  may  occur  at  any  age,  in  either  sex,  and  in 
every  race  and  country.  It  is  most  common  in  women  at 
about  the  age  of  twenty.  It  may  occur  in  early  childhood. 
Thus,  Clopatt,  in  a  total  of  272  cases,  gives  20  as  occurring 
previous  to  three  years  of  age.  It  is  especially  common 
among  the  Latin  races  and  Jews. 

Hysteria — symptoms :  These  are  divided  into  two  classes — 
the  jjaroxi/smal  and  the  interparoxysmal ;  the  former  tran- 
sient, the  latter  permanent. 

The  paroxysm :  This  is  best  known  by  the  term  hystero- 
epilepsy,  although  epilepsy  has  no  part  in  its  make-up,  unless 
both  diseases  occur  in  the  same  patient,  as  may  be  the  case. 
When  they  do,  however,  the  attacks  are  separate  and  distinct 
in  time  and  characteristics.  The  typical  attack  is  preceded 
several  days  by  prodromes  consisting  of  changes  in  mood, 
lack  of  concentration,  depression,  and  irritability.  As  the 
paroxysm  approaches  a  more  distinct  emotional  element  ap- 
pears :  tears  and  laughter  are  easily  excited,  and  alternate 
without  apparent  cause.  Hallucinations  may  also  be  present. 
Sometimes  the  patient  becomes  maniacal.  Some  of  the 
various  stigmata,  if  they  have  not  been  present,  appear. 
The  fit  may  be  ushered  in  by  the  globus  hystericus,  which  con- 
sists of  the  sense  of  a  ball  rising  in  the  throat,  attended  with 
a  sense  of  sufFocation  ;  the  clavus,  the  peculiar  headache  of 
hysteria  (p.  79),  which  may  be  accompanied  with  ringing 
noises  in  the  ears  and  ovarian  hypersesthesise. 

The  typical  convulsion,  as  described  by  Charcot  and  his 
followers,  is  divided  into  four  periods — i.  e.,  (1)  the  epilep- 
toid ;  (2)  the  period  of  grand  movements  ;  (3)  the  period  of 
passionate  attitudes  ;  (4)  the  period  of  delirium. 

The  first  stage  may  come  on  gradually  or  suddenly.     The 


HYSTERIA.  349 

face  becomes  pale,  the  eyes  staring,  and  the  patient  falls  or 
rather  sinks  gradually  to  the  floor.  It  is  rare  for  injury  to 
be  caused  by  tlie  fall,  as  in  epilepsy.  »Sighs,  groans,  or  ex- 
clamations may  be  uttered  and  the  body  becomes  rigid,  with 
a  tendency  to  opisthotonos.  The  face  is  slightly  congested 
and  there  may  be  some  frothing  at  the  mouth.  In  this  form 
of  attack  consciousness  may  be  completely  lost.  Following 
this  stage  several  clonic  movements  more  profusive  than 
those  of  epilepsy  and  embarrassed  respiration  occur.  This 
is  followed  after  a  few  minutes  by  a  brief  period  of 
more  or  less  complete  relaxation,  when  the  second  stage  is 
ushered  in. 

In  this  most  intense  rigidity  of  all  the  muscles  is  seen,  and 
marked  opisthotonos  occurs.  After  a  few  moments  this  is 
followed  by  rapid  flexions  of  the  upper  part  of  the  body, 
throwing  of  the  whole  body  from  side  to  side,  or  the  legs  are 
carried  to  the  vertical  position  and  then  violently  dropped 
again,  or  more  irregular,  incoordinate,  and  non-profusive 
movements  may  occur.  In  this  stage  there  is  no  facial  con- 
gestion and  the  respiration  is  about  normal. 

In  from  five  to  fifteen  minutes  the  third  stage  begins,  in 
which  the  emotions  not  under  control  are  expressed  by  gest- 
ures. Every  emotion  that  chances  to  pass  through  the  brain 
is  represented  by  its  appropriate  gesture.  During  this  period 
hallucinations  are  probably  present.  The  subjects  point  to 
objects  or  appear  to  be  listening  to  sounds.  They  imitate 
various  religious  ceremonies,  and  the  representation  of  the 
diiferent  emotional  states — viz.,  fear,  anger,  remorse,  sensu- 
ousness,  etc. — is  vivid  and  varied.  During  this  stage,  also, 
the  patient  may  sing  or  give  utterance  to  expressions  in  har- 
mony with  the  mental  state.     Sensory  stigmata  are  present. 

In  the  fourth  stage  the  patient  is  more  or  less  conscious  of 
his  surroundings.  Illusions  and  hallucinations,  usually  asso- 
ciated with  vision,  are  common.  The  patient  talks  inces- 
santly about  various  experiences  of  past  life.  Sermons  may 
be  preached  or  poems  recited.  The  cries  of  animals  may  be 
mimicked.  This  stage  may  continue  for  an  indefinite  period, 
sometimes  for  days,  sometimes  merging  into  either  mutism, 
trance,  or  lethargy.  In  addition  to  sensory  stigmata,  motor 
disturbances,  as  paralysis  or  contractures,  may  develop. 


350  GENERAL  AND  FUNCTIONAL  DISEASES. 

The  attack  as  seen  in  this  country  is  usually  atypical  and 
abortive.  It  may  consist  of  violent  alternate  weeping  and 
laughing,  or  in  addition  to  this  there  may  be  a  mild  degree 
of  rigidity  with  slight  clonic  movements.  In  this  form  of 
attack  consciousness  is  not  lost,  but  perverted.  The  patients 
often  describe  it  by  saying  that  they  can  hear  what  is  being 
said,  but  are  powerless  to  move  or  answer.  Partly  devel- 
oped third  and  fourth  stages — catalepsy,  lethargy  or  som- 
nambulism— may  follow,  and  also  any  of  the  various  motor 
or  sensory  stigmata. 

The  typical  convulsion  exclusive  of  the  fourth  stage  lasts 
from  one-quarter  to  half  an  hour,  and  is  known  as  hysteria 
major ;  the  abortive  attack  is  known  as  hysteria  minor. 

The  third  stage,  that  of  passionate  attitudes,  may  occur 
independently  of  the  other  stages,  and  is  known  as  ecstasy. 

Hysterical  somnambulism  also  at  times  occurs  independently. 
It  must  not  be  confounded  with  somnambulism  proper,  which 
is  an  affection  of  sleep.  It  is  also  a  modification  of  the  third 
stage ;  the  patient  remembers  what  occurred  during  the 
attack,  which  is  not  so  in  true  somnambulism.  Catalepsy  is 
a  condition  of  both  mental  and  motor  inertia.  In  it  the 
limbs  retain  for  long  periods  the  position  in  which  they  are 
placed.  When  bent  they  yield  like  a  lead  pipe.  The  patient 
is  apparently  insensible  to  external  impression  and  the  somatic 
functions  are  sluggish.  It  also  is  a  variation  of  the  third 
period.  It  occurs  also  in  some  forms  of  insanity,  and  can  be 
induced  by  hypnotism. 

Lethargy  is  also  a  shade  of  the  major  attack  or  may  be 
isolated.  In  it  the  patient  lies  in  a  semistupor,  with  closed 
eyes,  the  eyelids  presenting  fine  fibrillary  tremors.  This 
may  last  for  hours. 

Trance  is  an  intensification  of  lethargy.  In  it  the  brain 
functions  are  exercised  to  the  most  limited  extent  compatible 
with  the  maintenance  of  life.  This  condition  may  endure 
for  many  weeks.  During  the  attack  weight  is  lost.  Tem- 
perature, pulse,  and  respiration  are  not  much  affected. 
Pressure  over  the  hysterogenetic  zones  may  either  cause  or 
abort  an  attack  of  hysteria  major. 

Interparoxysmal    symptoms :   These   have   been    called    the 


HYSTERIA. 


351 


stigmata.     They  are  divided  into  sensory,  motor,  visceral,  and 
psychical : 

Sensory :  The  alterations  of  sensation  that  may  occur  are 

ancBsthesia,  hyjjercBsthesia,  and  jKcra^sthesia. 

Some  form  of  anaesthesia  is  the  most  common  of  all  the 
stigmata.  It  occurs  in  several  forms — viz.,  hemiancesthesia, 
which  extends  from  the  crown  of  the  head  to  the  soles  of 
the  feet,  often  involving  the  mucous  membranes,  subcuta- 
neous tissues  (even  the  nerves),  and  special  senses.  The  area 
stops  sharply  at  the  middle  line.     Vaso-motor  changes  often 

Fig.  71. 


Islets  of  ^^  Anaesthesia  (Pitres) 


accompany  it,  and  a  pin-prick  will  not  bleed.  The  limbs 
may  also  become  cedematous  and  mottled  (blue  oedema).  The 
sharp  line  of  demarcation,  the  contraction  of  the  visual  field, 


352 


GENERAL  AND  FUNCTIONAL  DISEASES. 


and  the  fact  that  by  suggestion  it  can  often  be  transferred 
from  one  side  to  the  other  distinguish  it  from  hemiansesthe- 
sia  of  organic  origin,  in  which  the  demarcation  is  not  so  sud- 
den ;  and  facial  paralysis  and  hemianopsia  are  usually  present. 


Fig.  72. 


Geometrical 


Anaesthesia  (Lloyd). 


Another  form  is  that  in  which  the  anaesthesia  occurs  in  scat- 
tered patches  assuming  various  shapes  (Fig.  71).  They  fre- 
quently change  their  position  from  day  to  day.  A  common 
variety  is  the  segmental  form,  in  which  the  ana?sthesia  is  lim- 
ited to  one  limb  or  part  of  a  limb.  It  presents  a  sharp  line 
of  demaveation,  often  resembling  a  stocking  or  a  glove  (Fig. 
72). 

Rarely  the  entire  person  may  be  antesthetic.  All  forms  of 
sensation — /.  c,  tactile,  pain,  temperature,  and  muscle-sense, 
— may  be    deficient,  or  only  one   of   them.      According   to 


HYSTERIA.  353 

Pitres,  the  anaesthesia  of  hysteria  is  never  isolated  tactile 
anaesthesia,  one  or  more  of  the  other  forms  being  always  com- 
bined with  it.  That  most  commonly  observed  is  loss  of  all 
forms,  followed  according  to  frequency  by  analgesia,  thermo- 
ansesthesia,  combined  tactile  and  thermo-ansesthesia,  elcctro- 
ansesthesia,  and  loss  of  all  modes  except  electro-ansesthe- 
sia.  The  degree  of  ansestliesia  may  vary  from  slight  dimi- 
nution in  acuteness  of  perception  to  absolute  loss.  It  is 
exaggerated  after  a  paroxysm.  Patients  are  often  unaware 
of  its  existence,  and  it  should  always  be  searched  for. 
While  common,  it  is  not  present  in  all  cases.  In  Briquet's 
series,  anaesthesia  in  some  degree  was  found  in  60  j)er  cent. 
The  skin-reflexes  in  the  anaesthetic  cases  are  absent  or  les- 
sened. The  special  senses  are  frequently  involved,  that  of 
sight  being  most  common.  It  may  be  totally  abolished  or 
partially  obscured. 

Complete  blindness  is  rare ;  it  may  appear  suddenly  and 
disappear  equally  so.  On  the  other  hand,  it  may  persist  a 
long  time.  It  is  sometimes  unilateral.  When  subjected  to 
proper  tests,  it  can  be  proved  that  patients  with  unilateral 
blindness  really  see  out  of  both  eyes ;  for  instance,  if  a  stere- 
opticon  is  looked  through,  tlie  picture  appears  just  as  it  should 
when  seen  by  means  of  both  eyes,  and  not  as  if  only  seen 
Avith  one.  This  is  explained  V)y  the  fact  that  the  loss  of  sight 
is  purely  psychical — /.  e.,  the  sensory  images  while  perceived 
do  not  enter  into  that  chain  of  associated  ideas  which  consti- 
tutes the  individual's  personality  ;  and  it  is  not  necessarily 
evidence  of  malingering.^  Partial  blindness  is  more  common, 
and  is  indicated  by  abnormalities  of  the  visual  field.  Rarely 
there  may  be  found  a  central  area  in  which  nothing  is  seen, 
while  in  the  periphery  sight  is  retained  (central  scotomata). 
Equally  rare  is  homonymous  hemianopsia,  distinguished  from 
that  due  to  organic  disease  by  the  presence  of  hysterical 
hemianaesthesia  and  involvement  of  other  special  senses  on 
that  side  and  the  raucous  membranes;  and  great  contrac- 
tion of  the  preserved  fields  (Fig.  73).  But  one  of  the  most 
common  of  the  sensory  stigmata  is  concentric  narrowing  of 
the  field,  which  may  be  round,  oval,  or  irregular  in  outline 
(Figs.  74  and  75).     The  perception  of  colors  may  be  affected ; 

'See  article  by  Prince,  Amer.  .Jour.  Med.  Sci.,  vol.  xciii.  p.  157. 
23— N.  D. 


354 


GENERAL  AND  FUNCTIONAL  DISEASES. 


either  lost  (achromatopsia)  ;  or  what  is  more  common,  per- 
verted (dyschromatopsia).  In  the  normal  eye  colors  are  not 
perceived  with  equal  acuteness,  the  normal  order  being  blue, 


Diafframs  of  fields  of  vision  in  a  case  of  hysterical  homonymous  hemianopsia 

(Lloyd). 

yellow,  red,  green,  and  violet.  In  hysteria  this  order  may  be 
changed,  and  red  be  perceived  before  blue,  and  so  on  (see  Fig. 
76).  Instead  of  this,  the  color-fields  may  be  concentrically 
narrowed  in  the  order  of  their  normal  position.     Hysterical 


HYSTERIA. 


355 


deafness  frequently  accompanies  hemiansesthesia.     It  is  rare 
for  it  to  be  either  isolated  or  complete. 

Smell  and  taste  may  also  be  impaired ;    usually  unilater- 
ally, as  an  accompaniment  of  liemiansesthesia. 


Fig.  74. 


Irregular  contraction  of  the  visual  field  in  one  eye  in  traumatic  hysteria  (Knapp) 

Hypersesthesia  is  an  important  symptom,  as  it  is  the  cause 
of  the  so-called  hysterogenous  zones.  These  are  localized 
hypersensitive   areas,   pressure  upon  which  will  excite  the 


356 


GENERAL  AND  FUNCTIONAL  DISEASES. 


paroxysmal  manifestations,  especially  convulsions,  and  will 
also  cause  them  to  cease  when  developed.  They  are  most 
commonly  found  over  the  ovaries,  on  the  breasts,  along  the 


Fig.  75. 


Marked  contraction  of  both  visual  fields  in  hysteria  (Gilles  de  la  Tourette). 


spine,  and  on  the  trunk  beneath  the  ribs.  They  may  also  be 
the  seat  of  spontaneous  pain,  and  hence  simulate  local  in- 
flammations. This  is  especially  true  of  joints,  oro;anic  in- 
flammation of  which  may  be  closely  simulated.     Hysterical 


HYSTERIA. 


357 


joints  are  not  associated  with  deformity,  shortening,  develop- 
ment of  pus,  or  elevation  of  temperature.     There  are  usually 


Diagrams  of  fields  of  vision  in  a  case  of  hysteria,  showing  normal  form  fields  and 
reversal  of  the  red  and  blue  lines,  the  red  field  being  largest  in  extent  (Mitchell 
and  de  Schweinitz). 

-.-.-=  red.    =  blue =  green. 


marked  contractures,  more  pronounced  than  the  degree  of 
muscular  rigidity  common  about  inflamed  joints  ;  the  pain  is 
more  diffuse,  and  the  mental  and  physical  stigmata  of  hys- 


358  GENERAL  AND  FUNCTIONAL  DISEASES. 

teria,  as  paralysis  or  anaesthesia,  and  a  tendency  to  exaggera- 
tion in  the  account  of  the  symptoms  is  apt  to  coexist. 
Under  ether  the  joint  will  be  found  to  be  freely  movable. 
Of  course,  as  in  other  conditions,  hysteria  may  be  added  to 
an  organic  affection.  Various  forms  of  neuralgic  pain  occur, 
as  the  clavus  already  described ;  in  the  female  breast,  which 
may  be  accompanied  with  great  tenderness  and  some  swell- 
ing; and  in  the  occiput,  back  of  the  neck,  and  along  the 
spine. 

Parsesthesia  when  present  usually  takes  the  form  of  flashes 
of  heat  or  cold ;  sensations  of  insects  crawling  over  the 
body,  which  may  be  also  associated  with  hallucinations  ;  of 
numbness,  not  dependent  upon  ansesthesia ;  of  prickling, 
tingling,  burning,  and  the  like. 

Motor :  These  consist  of  paralysis,  contracture,  tremor,  and 
incodrdination. 

Paralysis  may  take  the  form  of  either  monoplegia,  hemi- 
plegia, paraplegia,  diplegia,  or  be  limited  to  a  few  muscles  or 
muscle-groups.  It  may  be  either  caused  or  aggravated  by  a 
previous  convulsion,  or  follow,  independently  of  this,  any  of 
the  causes  mentioned  under  etiology.  Contracture  is  fre- 
quently, but  not  always,  associated  with  it.  The  degree  of 
paralysis  varies  from  slight  weakness  (amyosthenia)  to  com- 
plete loss  of  power.  The  deep  reflexes  are  usually  some- 
what increased^  or  normal  and  the  skin-reflexes  abolished. 
The  loss  of  power  frequently  develops  either  gradually  or 
suddenly,  and  may  disappear  suddenly,  or  it  may  persist  for 
a  long  time. 

Monoplegia  is  generally  accompanied  by  ansesthesia,  which 
assumes  the  glove-like  or  segmental  form,  and  does  not  fol- 
low the  distribution  of  the  nerves,  as  does  ansesthesia  due  to 
peripheral  nerve  lesion. 

In  hysterical  hemiplegia  the  weakness  is  generally  more 
marked  in  the  leg  than  in  the  arm.  The  face  and  tongue 
are  very  rarely,  if  ever,  paralyzed,  but  these  muscles  may  be 
affected  by  contracture.  In  walking  the  leg  is  dragged  after 
the  patient,  and  is  not  swung  in  the  arc  of  a  circle,  as  in 

^  Whether  ankle-clonus  is  ever  due  to  hysteria  or  not  is  a  disputed  point, 
there  being  good  authority  advocating  botli  views. 


HYSTERIA.  359 

organic  hemiplegia.  There  is  often  ansesthesia,  either  involv- 
ing the  same  side  (hemiansesthesia)  or  in  disseminated  areas. 
What  promises  to  be  an  important  diagnostic  sign  is  the  state- 
ment of  Babinski,  that  the  toe  is  flexed  in  the  normal  manner 
when  the  plantar  reflex  is  tested,  and  not  as  it  is  in  organic 
hemiplegia  (see  Plantar  Reflex). 

Paraplegia  may  resemble  very  much  that  due  to  organic 
causes,  but  it  difiers  in  the  mode  of  onset ;  the  sphincters  not 
being  involved ;  absence  of  trophic  symptoms ;  normal  or 
but  slightly  increased  reflexes,  and  in  the  fact  that  the  area 
of  anaesthesia,  if  present,  does  not  correspond  to  that  which 
would  be  caused  by  an  organic  lesion  if  the  motor  paralysis 
present  were  due  to  such. 

Local  paralyses  may  afifect  a  muscle  or  group  of  muscles 
of  a  limb,  or  those  of  the  eye,  larynx,  pharynx,  or 
oesophagus. 

Paralysis  of  the  ocular  muscles,  intrinsic  or  extrinsic,  is 
rare,  but  does  occur. 

The  vocal  cords  are  often  paralyzed,  producing  aphonia ;  a 
slight  cold  or  sore  throat  may  produce  it.  It  is  usually  bi- 
lateral, and  the  adductors  are  the  muscles  aifected  (see  p.  140). 
Rarely  the  abductors  may  be  involved.  Anaesthesia  of  the 
laryngeal  mucus  membrane  may  coexist,  and,  if  present,  is 
a  valuable  symptom.  In  paralyses  of  the  pharynx  and 
oesophagus  there  is  interference  with  deglutition  and  a  sense 
of  constriction.  Examination  with  a  bougie  will  fail  to  find 
evidence  of  stricture. 

Often  in  hysteria  the  stomach  and  intestines  become  greatly 
distended  with  gas,  forming  apparent  tumor  (phantom  tumor), 
or  simulating  pregnancy.  Probably,  in  some  instances  at 
least,  this  is  due  to  paralysis  of  the  muscles  of  the  intestine. 

Contracture  is  a  characteristic  symptom  of  hysteria,  and 
usually,  but  not  always,  is  associated  with  paralysis.  It  may 
involve  all  the  muscles  of  a  limb  or  only  a  few  of  them. 
Its  onset  may  be  sudden  or  gradual ;  most  frequently  the 
former.  It  often  disappears  suddenly  and  reappears  in  an- 
other part.  It  is  very  obstinate  and  difficult  to  overcome. 
It  may  not  relax  during  sleep,  but  does  so  under  an  anaes- 
thetic. It  may  be  painful  ;  the  deformity  often  assumes 
forms  not  common  to  those  due  to  organic  disease ;  compare 


360  GENERAL  AND  FUNCTIONAL  DISEASES. 

that  seen  in  Fig,  77  with  the  contracture  due  to  organic 
hemiplegia  in  Fig.  36. 

Contractures  also  occur  in  the  muscles  of  the  face,  tongue, 
eyes,  and  neck.  The  muscles  of  the  face  and  tongue  are 
often  involved  in  hemiplegia.  They  usually  produce  de- 
formities not  similar  to  those  which  would  be  produced  by  a 

Fig.  77. 


Hysterical  contracture  (Methodist  Episcopal  Hospital,  Philadelphia). 

hemiparesis  of  these  muscles  accompanying  hemiplegia ;  thus 
the  tongue  may  be  protruded  away  from  the  paralyzed  side, 
instead  of  toward  it,  as  in  organic  hemiplegia.  Contracture 
of  some  of  the  eye-muscles,  producing  blepharospasm,  may 
be  present  at  the  same  time.  The  eye-muscles  are  much 
more  frequently  the  seat  of  contracture  than  of  paralysis ; 
apparent  ptosis  may  be  so  caused,  and  double  vision  is  some- 
times a  consequence.  Torticollis  would  be  produced  by  con- 
tracture of  the  neck-muscles.     Cases  have  been  reported  in 


HYSTERIA.  361 

which,  associated  with  other  stigmata  of  hysteria,  there  have 
been  clicking  noises,  which  are  audible  to  a  person  listening 
a  few  inches  from  the  ear.  These  have  been  thought  to  be 
due  to  clonic  spasm  of  the  soft  palate  and  pharyngeal 
muscles. 

Tremor  most  frequently  occurs  in  cases  due  to  traumatism, 
or  the  action  of  toxic  agents,  as  alcohol,  lead,  or  mercury. 
While  these  may  cause  tremor  by  their  toxic  influence  upon 
the  nervous  system,  Avhich  is  then  not  hysterical,  in  some  cases 
the  tremor  is  due  to  fear  of  being  poisoned  and  to  the  in- 
fluence of  fear  upon  the  individual.  It  may  be  rapid  or  slow, 
and  often  occurs  as  an  intention-tremor,  simulating  that  of 
multiple  sclerosis. 

Sharp,  quick  muscular  contractions,  producing  movements 
resembling  choreic  movements,  are  sometimes  seen.  They 
differ  from  choreic  movements  in  that  they  are  much  quicker 
and  more  co5rdinate,  while  other  stigmata  of  hysteria  will  be 
present. 

Incoordination  may  vary  from  a  slight  loss  of  control  over 
either  all  or  a  few  muscles  to  the  symptom-complex  known 
as  astasia-abasia.  This  is  most  frequently  seen  in  children, 
and  is  characterized  by  inability  either  to  stand  or  walk, 
while  the  muscular  strength  of  the  legs  and  ability  to  exe- 
cute coordinate  movements  is  preserved  when  the  patient 
reclines  or  sits.     Aneesthesia  may  or  may  not  be  present. 

Visceral  symptoms  :  Among  visceral  symptoms  due  to  hvs- 
teria  are  vomiting,  cardiac,  vascular,  and  vasomotor  affections, 
rapid  respiration,  pyrexia,  cough,  yawning,  phantom  tumors, 
and  anuria. 

Hysterical  vomiting,  also  known  as  anorexia  nervosa,  is 
characterized  by  the  absence  of  nausea,  the  food  being  regur- 
gitated without  eifort.  In  some  cases  it  does  not  reach  the 
stomach  at  all.  Sometimes  there  is  merely  prolonged  refusal 
of  food  and  absence  of  vomiting.  Such  patients  may  become 
extremely  emaciated.  The  usual  sudden  onset  after  exposure 
to  a  cause  of  hysteria,  character  of  the  vomiting,  and  the 
presence  of  other  hysterical  stigmata  distinguish  it  from  that 
due  to  organic  disease. 

Symptoms  pertaining  to  the  circulatory  apparatus  consist 


362  GENERAL  AND  FUNCTIONAL  DISEASES. 

of  either  rapid  or  slow  pulse ;  flushings ;  cedenia,  which  does 
not  pit  on  pressure,  the  skin  over  it  being  normal  or  blue  in 
color ;  erytiiema ;  or  the  smaller  vessels  may  be  contracted, 
as  evidenced  by  the  absence  of  bleeding  when  the  ansesthetic 
limb  is  punctured. 

Rapid  respiration  is  not  necessarily  accompanied  by  rapidity 
of  the  heart,  and  there  is  neither  dyspnoea  nor  cyanosis.  It 
may  be  as  high  as  90  to  the  minute. 

Hysterical  fever  may  occur  without  other  symptoms. 
When  accompanied  with  pain  it  simulates  other  affections,  as 
meningitis  or  other  organic  disease.  Only  the  prolonged 
course  of  the  disease,  some  atypical  symptom,  or  develop- 
ment of  typical  hysterical  stigmata  enable  the  diagnosis  to 
be  made. 

Hysterical  cough  is  persistent,  dry,  and  brazen,  and  does 
not  appear  to  annoy  the  patient.  Paroxysms  of  gaping  is  a 
rare  symptom. 

Anuria  is  not  a  common  symptom.  An  excessive  flow  of 
urine  (polyuria)  is  more  common. 

Psychical  symptoms :  Preceding  convulsive  seizures  or  oc- 
curring independently,  there  may  be  attacks  characterized  by 
the  occurrence  of  delusions  associated  with  either  depressions, 
exaltation,  or  an  alternation  of  the  two  states.  Such  attacks 
have  been  called  hysterical  insanity.  Investigation  will  usu- 
ally determine  the  existence  of  some  of  the  hysterical  stig- 
mata or  the  previous  occurrence  of  convulsive  seizures. 

Hysteria — pathology :  Nothing  positive  is  known  of  the 
pathology  of  hysteria.  Such  patients  are  peculiarly  liable  to 
be  impressed  by  suggestions.  They  may  come  from  without 
or  within  ;  thus  a  slight  twist  of  the  ankle  causes  the  devel- 
opment of  a  hysterical  joint,  and  so  on.  It  is  possible  also 
that  dreams  and  nightmares  may  act  as  suggestive  agents. 

Diagnosis :  While  hysteria  may  simulate  all  diseases,  it  also 
possesses  certain  peculiarities  which  should  enable  us  to  recog- 
nize its  existence.  There  will  always  be  found  something 
not  typical  of  the  organic  disease,  but  which  is  peculiar  to 
hysteria. 

These  peculiarities  have  been  detailed  under  the  descrip- 
tion of  various  symptoms.     The  points  of  distinction  between 


TRAUMATIC  NEUROSES.  363 

the  epileptic  and  hysterical  convulsion  have  been  given  on  p. 
338 ;  between  neurasthenia  and  hysteria,  on  p.  345. 

A  striking  peculiarity  of  hysteria  not  found  in  any  other 
disease,  excepting  syphilis  of  the  nervous  system,  is  sudden 
appearance,  disappearance,  and  shifting  of  the  symptoms. 
This,  of  course,  does  not  occur  in  all  cases  ;  but  when  it  does, 
it  is  suggestive.  The  distinction  between  syphilis  and  hys- 
teria should  be  easily  made  by  paying  attention  to  the  exist- 
ence of  the  stigmata  above  mentioned.  It  must  not  be 
forgotten  that  hysteria  may  coexist  with  many  organic  dis- 
eases of  the  nervous  system  and  forms  of  insanity. 

Prognosis  :  This  is  doubtful ;  death  is  rarely  caused  by  hys- 
teria; but  the  symptoms  may  obstinately  resist  all  treatment. 
On  the  other  hand,  some  mental  impression  or  other  agency, 
may  cause  a  sudden  recovery. 

Hysteria— treatment :  In  the  treatment  of  the  disease,  the 
tendency  to  receive  suggestions  must  be  remembered.  To 
utilize  suggestion,  hypnotism  is  not  essential ;  all  that  is  neces- 
sary is  first  to  gain  the  patients'  confidence,  and  then  contin- 
ually to  impress  upon  them  that  certain  effects  will  result 
from  certain  causes.  Electricity,  especially  the  static  form, 
is  a  useful  adjuvant  in  impressing  the  patient.  Massage  is 
also  of  service.  Some  unpleasant  form  of  treatnaent  may 
also  be  of  service ;  for  instance,  if  in  a  robust  patient  cold 
douches  or  plunge  baths,  or  hot  and  cold  douches  followed  by 
frictions,  are  often  useful.  The  actual  cautery  may  also  exert 
a  good  influence.  The  general  condition  of  the  patient  should 
be  built  up  and  supported,  and  drugs  should  be  used  only  to 
exert  that  end.     The  prolonged  use  of  sedatives  is  harmful. 

In  all  cases  it  is  of  advantage — often  in  fact,  a  necessity — to 
remove  the  patient  from  the  influence  of  sympathizing  friends 
and  relatives.  Hence  it  is  that  the  rest  treatment  of  Weir 
Mitchell  is  often  productive  of  satisfactory  results.  A 
hysterical  paroxysm  can  often  be  cut  short  by  a  hypoder- 
matic injection  of  apomorphine  or  the  vigorous  use  of  cold 
water. 

TRAUMATIC  NEUROSES. 

Definition :  Various  organic  affections  of  the  nervous  sys- 
tem may  be  due  to  trauma.     Thus,  definite  changes  in  its 


364  GENERAL  AND  FUNCTIONAL  DISEASES. 

structure  may  be  caused  by  contusion  or  crushing  of  the 
tissues  or  by  hemorrhages,  single  or  multiple.  Injuries,  with- 
out discoverable  external  lesion,  may  cause  diminished  resist- 
ance to  the  action  of  infections,  and  thus  give  rise  to  the  de- 
velopment of  disease  from  such  cause.  Epilepsy,  multiple 
sclerosis,  myelitis,  progressive  muscular  atrophy,  and,  possi- 
bly, tabes  and  tremor,  may  be  the  results  of  a  previous 
trauma.  The  functional  disorders,  either  neurasthenia  or 
hysteria,  may  also  be  caused  by  trauma,  and,  when  symptoms 
of  either  of  these  or  of  both  combined,  follow  this  cause,  the 
patient  is  said  to  have  a  traumatic  neurosis.  The  names 
"railway  brain"  and  "railway  spine"  have  also  been  applied. 

Etiology :  Traumatic  neuroses  may  be  caused  by  any  sort 
of  injury,  and  seem  especially  liable  to  result  from  an  injury 
which  gives  rise  to  jarring  or  concussion  of  the  whole  body. 
An  important  element  in  the  etiology  is  the  coexistence  of 
fright  or  mental  shock,  and  very  trifling  physical  injury  may 
be  sufficient  to  produce  the  symptoms  if  so  accompanied. 
Indeed,  mental  shock  alone  may  be  sufficient.  In  some  cases, 
when  blows  upon  the  back  are  received,  actual  damage  may 
be  done  to  the  intervertebral  joints,  causing  certain  symptoms 
to  be  described  later.  As  has  been  shown  under  the  descrip- 
tion of  these  affections,  patients  with  neurasthenia  or  hysteria 
are  introspective ;  they  are  continually  watching  their  old 
symptoms  and  hunting  for  new  ones. 

The  latter  also  are  prone  to  receive  suggestions.  Now,  as 
the  traumatic  cases  are  often  the  cause  of  litigation,  they  are 
subjected  to  examinations  by  lawyers  and  physicians  and  to 
the  worry  and  excitement  which  attends  all  litigation,  which 
factors  tend  at  least  to  aggravate  unconsciously  the  condition. 
It  must  not  be  supposed  that  all  such  cases  are  subjects  of 
litigation.  They  frequently  occur  when  such  is  not  thought 
of  or  possible. 

Traumatic  neurosis — symptoms  :  If  the  injury  is  severe  the 
ordinary  symptoms  of  concussion  of  the  brain  (if  cerebral),  or 
of  ordinary  surgical  shock  if  elsewhere,  occur  at  once.  If 
the  injury  is  slight,  tlie  patient  may  be  thrown  at  once  into  a 
dazed  condition,  in  whicli  he  performs  various  actions  cor- 
rectly, but  may  liave  no  remembrance  of  them  afterward  ;  or 
he  may  be  dazed  for  a  moment,  then  recover,  and,  after  a 


TRAUMATIC  NEUROSES. 


365 


greater  or  less  period  of  time,  the  syniptoius  develop.  In  a 
few  hours,  in  some  eases,  the  patient  may  be  seized  with  a 
spell  of  hysterical  weeping  or  he  maybe  unable  to  sleep.  In 
others  the  symptoms  develo])  gradually,  ami  it  may  be  several 
weeks  before  anything  noticeably  wrong  is  discovered.     The 


Fui.  78. 


Attitude  of  a  patient  with  traumatic  lumbago  iDercum). 


symptoms,  when  fully  developed,  consist  of  various  combina- 
tions of  those  described  under  hysteria  and  neurasthenia. 

When  there  has  been  a  direct  blow  upon,  or  twisting  or 
wrenching  of  the  back,  the  intervertebral  joints  or  the  muscles 
maybe  damaged,  and  the  condition  known  as  traumatic  lum- 
bago produced.  This  is  characterized  by  pain  in  the  back, 
much  increased  by  movement.  The  muscles  are  in  a  state  of 
rigidity  also  increased  by  attempts  at  movement.     The  pa- 


366  GENERAL  AND  FUNCTIONAL  DISEASES. 

tieiit  walks  slowly  and  deliberately,  holding  the  back  stiflfly 
(Fig.  78).  Pain  is  elicited  by  deep,  hard  pressure  over  the 
affected  areas. 

Traumatic  neurosis — diagnosis ;  It  is  necessary  first  to  de- 
termine that  the  patient  is  not  simulating.  To  do  so,  repeated 
and  careful  examinations  must  be  made,  taking  care  not  to 
ask  leading  questions.  The  presence  of  objective  symptoms, 
as  contracted  visual  fields,  tachycardia,  areas  of  anaesthesia 
found  in  the  same  areas  at  successive  examinations,  con- 
tractures, etc.,  woidd  be  of  great  assistance  in  determining 
that  the  condition  was  genuine.  When  the  symptoms  are 
entirely  subjective  the  decision  may  be  more  difficult.  It  is 
not  often,  however,  that  a  layman  would  be  able  to  detail  a 
group  of  symptoms  characteristic  of  the  genuine  condition, 
and  repeat  the  same  without  essential  variation  at  different 
examinations.  As  a  matter  of  experience,  simulation  of  these 
conditions  is  rare. 

Having  determined  that  there  is  a  genuine  disorder,  it  may 
be  necessary  to  determine  that  no  organic  disease  of  the 
nervous  system  is  present,  or,  if  a  joint  is  affected,  whether 
the  affection  is  organic  or  hysterical.  For  the  distinguishing 
features  the  reader  is  referred  to  the  description  of  hysteria, 
neurasthenia,  and  organic  diseases  of  the  nervous  system. 

The  prognosis  of  traumatic  neurosis  as  to  complete  recovery 
is  doubtful.  Not  much  improvement  can  be  hoped  for  Mobile 
legal  proceedings  are  in  progress.  After  the^y  cease,  some 
improvement,  as  would  naturally  be  expected,  often  occurs, 
but  complete  recovery  cannot  safely  be  promised,  and  as  a 
fact  rarely  happens.  Traumatic  lumbago  is  an  obstinate 
affection.  If  put  under  the  proper  conditions  early,  cases  of 
traumatic  neurasthenia  often  do  well. 

Traumatic  neurosis — treatment :  This  should  be  instituted 
early,  and  the  vexatious  excitement  and  examinations  incident 
to  legal  proceedings  avoided  if  possible.  Hence  an  early  set- 
tlement should  be  advised  in  preference  to  a  jury  trial,  even 
if  the  compensation  is  likely  to  be  less.  The  patient  should 
be  encouraged  and  conversation  referable  to  the  accident  or 
symptoms  suffered  from  avoided.  The  rest  treatment  of 
Weir  Mitchell,  when  it  can  be  obtained,  is  the  preferable 
form  of  treatment.     If  it  cannot  be,  other  measures  advised 


OCCUPATION-NEUROSES.  367 

for  the  treatment  of  neurasthenia  and  hysteria  may  be  em- 
ployed. 

For  traumatic  lumbago,  rest  in  bed,  gentle  massage  of  the 
affected  muscles,  the  galvanic  current,  the  anode  being  placed 
over  the  tender  points,  should  be  employed.  In  extreme 
cases,  counter-irritation,  preferably  with  the  actual  cautery, 
may  be  tried. 

OCCUPATION-NEUROSES. 

Definition :  An  occupation-neurosis  is  a  condition  occurring 
in  persons  whose  business  requires  the  constant  repetition  of 
certain  movements  which,  in  most  cases,  are  line  and  compli- 
cated, but  may  be  simple  and  coarse,  in  which  they  lose  the 
power  of  performing  these  movements,  while  all  other  move- 
ments can  be  performed  as  usual. 

Etiology:  It  is  most  apt  to  occur  in  neurotic  individuals, 
especially  those  who  are  neurasthenic,  and  anything  which 
acts  as  a  cause  in  producing  that  condition  may  act  as  a  pre- 
disposing cause  in  the  development  of  an  occupation-neurosis. 
It  is  more  common  in  men  than  in  women. 

The  most  common  cause  of  this  condition  is  excessive 
writing,  and  when  so  produced  is  known  as  writers'  cramp,  or 
writers'  or  scriveners'  palsy. 

Occupation-neuroses — symptoms  :  Writers'  cramp  :  Three 
types  have  been  described — ^.  e.,  the  paralytic,  the  spasmodic, 
and  the  tremulous.  They  are  rarely  sharply  defined,  the 
symptoms  of  each  more  or  less  commingling.  Usually  the 
first  symptom  noticed  is,  that  after  v/riting  awhile  a  dull  ache 
in  the  wrist  and  metacarpal  joints,  and  a  sense  of  fatigue 

Fig.  79. 


Handwriting  in  case  of  writers'  cramp.    The  patient  could  not  make  another  letter 

in  this  attempt  to  write  his  name. 


is  felt.  After  ceasing  to  write,  this  passes  away  to  return 
again  at  the  next  attempt.  Finally,  these  symptoms  re- 
main permanent  and  may  extend  up  the  arm  even  to  the 


368  GENERAL  AND  FUNCTIONAL  DISEASES. 

scapula.  Soon  motor  symptoms  appear ;  the  patient  cannot 
control  the  pen  ;  it  digs  into  the  paper  or  flies  about  in  va- 
rious directions  ;  or  it  is  grasped  tightly  and  there  is  inability 
to  move  it  in  any  direction  (Fig.  79) ;  or  the  pen  is  dug  tightly 
into  the  paper,  making  characters  such  as  are  seen  in  Fig.  80. 

Fig.  80. 


Handwriting  in  writers'  cramp. 

More  rarely  the  pen  drops  from  the  fingers.  The  spasm  is 
tonic,  not  clonic.  Sometimes  the  muscles  of  the  arm  and 
shoulder  may  be  aifected  in  addition  to  those  of  the  thumb 
and  fingers.  If  tremor  occurs,  the  handwriting  is  shaky  and 
tremulous ;  it  is  usually  only  present  during  the  attempt  to 
write,  but  in  advanced  cases  may  be  continuous.  There  is 
usually  some  degree  of  spasm  also  present. 

As  a  rule,  all  movements  excepting  those  employed  in 
writing  can  be  well  performed.  Sometimes,  however,  there 
may  be  involvement  of  some  others,  as  in  a  patient  reported 
by  Gowers,  who  also  lost  the  ability  to  shave.  Tender  points 
are  often  found  over  the  nerve-trunks,  and  paresthesias  of 
various  sorts  may  be  present.  The  general  condition  of  the 
patient  is  apt  to  be  neurasthenic. 

There  are  a  number  of  other  occupations  which  may  pro- 
duce similar  symptoms,  only  diflFering  in  the  character  of  the 
movements  affected.  They  are  principally  found  in  seam- 
stresses, telegraph-operators,  piano-players,  type-writers,  and 
blacksmiths.  Cases  have  also  been  reported  in  drummers, 
money-counters,  weavers,  compositors,  engravers,  dancers, 
cigarette-makers,  painters,  and  others. 

Occupation-neuroses — diagnosis :  The  early  stages  may  be 
mistaken  for  neuritis  ;  but  the  fact  that  all  other  movements 
can  be  well  performed  eliminates  that. 

The  prognosis  as  regards  recovery  is  not  very  good,  espe- 
cially if  the  case  is  of  long  standing.  Recoveries,  however, 
do  occur. 


TETANUS.  369 

Occupation-neuroses — treatment:  The  most  essential  thing 
is  the  prohibiting  of  the  performance  of  the  affected  move- 
ments. If  this  is  impossible,  in  some  occupations  the  use  of 
the  left  hand  may  be  learned,  although  this  may  also  become 
affected  in  time.  In  writing,  a  soft  pen,  thick  holder,  and  a 
free  arm-movement  should  be  employed.  Such  precautions 
are  also  of  value  in  preventing  the  appearance  of  the  disease. 
The  general  health  must  be  built  up  by  appropriate  measures 
(see  Neurasthenia).  Galvanism,  the  anode  applied  labile 
over  the  muscles  of  the  arm  for  five  minutes,  followed  by  a 
constant  current  passed  down  the  arm  for  ten  minutes,  often 
gives  relief.  Massage  is  also  useful.  Out-door  exercise  and 
local  gymnastics,  the  fingers  being  made  to  perform  various 
movements  unlike  those  affected,  often  give  excellent  reslilts. 
The  various  appliances  which  have  been  invented  to  enable 
the  patient  to  write,  soon  lose  their  efficiency. 

TETANUS  (LOCKJAW). 

Definition :  An  acute  or  subacute  infectious  disease,  charac- 
terized by  tonic  spasm,  with  violent  exacerbations,  without 
loss  of  consciousness. 

Etiology :  It  occurs  "  idiopathically,"  or  after  trauma.  In 
certain  localities  it  occurs  in  epidemic  form  among  newborn 
children  (trismus  neonatorum).  It  is  more  common  in  hot 
than  temperate  climates.  Most  cases  follow  wounds,  usually 
punctured,  of  the  hands  and  feet.  A  very  trifling  wound 
may  be  sufficient.  It  also  occurs  in  women  after  childbirth. 
The  essential  cause  is  the  tetanus  bacillus. 

The  symptoms  of  tetanus  generally  appear  within  ten  days 
after  the  injury.  A  feeling  of  stiffness  in  the  neck  or  diffi- 
culty in  mastication  is  first  complained  of.  Gradually  a 
tonic  spasm  of  the  muscles  of  mastication  develops,  produc- 
ing the  condition  of  trismus,  or  lockjaw.  The  eyebrows  may 
be  raised  and  the  angles  of  the  mouth  drawn  out,  producing 
the  so-called  risus  sardonicus.  By  degrees  the  muscles  of 
the  body  are  involved.  During  the  height  of  the  spasm  the 
body  assumes  the  position  of  opisthotonos ;  or,  less  com- 
monly, the  body  and  limbs  may  be  rigid  (orthotonos) ;  or 
flexed  to  one  side  (pleurothotonos) ;  or  spasm  of  the  abdominal 
24— N.  D. 


370  GENERAL  AND  FUNCTIONAL  DISEASES. 

muscles  may  cause  it  to  be  bent  forward  (emprosthotonos). 
During  the  paroxysm  the  respirations  are  rapid,  and  spasm 
of  the  glottis  may  cause  asphyxia.  The  slightest  irritation  is 
sufficient  to  cause  a  spasm,  which  lasts  for  varying  periods, 
but  complete  relaxation  does  not  occur  in  the  intervals.  The 
temperature  may  be  either  normal  or  considerably  elevated 
(105°-106°  F.).  Consciousness  is  preserved,  and  severe  pain 
attends  the  paroxysms. 

A  form  known  as  cephalic  tetanus  may  result  from  ^^■ounds 
on  one  side  of  the  head,  and  is  characterized  by  stiffness  of 
the  muscles  of  the  jaw,  paralysis  of  t-he  facial  muscles  on  the 
same  side  as  the  wound,  and  difficulty  in  swallowing. 

Pathology  :  No  characteristic  lesions  have  been  found.  The 
disease  is  due  to  infection  by  virus  produced  by  a  bacillus 
which  is  found  in  the  earth,  in  putrefying  fluids,  and 
manure. 

Diagnosis :  Tetanus  resembles  strychnine-poisoning,  but  in 
the  jaw-muscles  are  not  involved  first  and  there  is  no  rigidity 
between  the  paroxysms,  or  elevation  of  temperature.  The 
points  that  distinguish  it  from  tetany  are  given  under  the 
account  of  that  disease. 

The  prognosis  is  bad.  Chronic  or  subacute  cases — those  in 
which  the  symptoms  develop  late,  in  which  the  spasms  are 
localized  to  the  muscles  of  the  neck  and  jaw,  and  in  which 
fever  is  absent — frequently  recover.  It  is  worse  in  traumatic 
cases  than  in  the  "idiopathic."  Cases  that  live  over  four 
days  usually  recover. 

Tetanus — ^treatment :  The  wound,  if  found,  should  be  ex- 
cised and  antiseptic  treatment  employed.  The  patient  must 
be  kept  in  a  darkened  room  and  all  sources  of  irritation 
avoided.  If  food  cannot  be  taken  by  the  mouth,  he  may  be 
fed  by  nutritive  enemata,  or  through  a  catheter  introduced 
through  the  nose.  The  paroxysm  should  be  controlled  with 
chloroform.  Either  morphine,  chloral  hydrate,  or  the  bro- 
mides should  be  given  in  full  doses.  The  use  of  an  anti- 
toxin has  lately  been  recommended.  This  has  been  employed 
hypodermatically  or  by  injection  into  the  brain-substance. 
The  results  have  not  been  very  favorable. 


HYDROPHOBIA.  371 

HYDROPHOBIA  (RABIES). 

Definition :  An  acute  infectious  disease  of  carnivorous  ani- 
mals, wiiich  may  by  inoculation  be  transmitted  to  man  and 
other  animals. 

Etiology :  It  is  more  common  in  some  countries  than  in 
others ;  in  this  country  it  is  rare.  The  dog  is  particularly 
susceptible.  The  nature  of  the  poison  is  unknown.  It  is 
found  in  the  nervous  system  and  some  of  the  secretions,  nota- 
bly the  saliva.  All  persons  bitten  by  rabid  animals  do  not 
develop  the  disease.  About  15  per  cent,  of  these  are  bitten 
by  dogs. 

Hydrophobia — symptoms :  The  period  of  incubation  varies 
from  six  weeks  to  three  months.  There  is  first  a  premonitory 
stage,  in  which  there  may  be  irritation,  pain,  and  numbness 
about  the  bite.  There  are  headache,  loss  of  appetite,  de- 
pression of  spirits,  and  elevation  of  temperature.  There  are 
also  irritability  and  sleeplessness.  The  voice  may  be  husky 
and  some  difficulty  in  swallowing  be  experienced. 

Gradually  great  excitability,  restlessness,  and  hypersesthesia 
develop.  The  slightest  peripheral  irritation  causes  muscular 
spasm.  The  muscles  of  the  larynx  and  mouth  are  particu- 
larly affected,  and  the  attempt  at  swallowing  causes  painful 
spasms  of  these  muscles.  During  the  spasms  the  patient 
may  be  maniacal,  in  which  he  may  attempt  injury  to  other 
people.  This,  however,  is  unusual.  In  the  interval  between 
the  spasms  the  patient  is  quiet  and  rational.  The  tempera- 
ture is  usually  elevated. 

In  from  one  to  three  days  the  patient  passes  into  the  so- 
called  paralytic  stage.  He  becomes  quiet,  the  spasms  cease, 
unconsciousness  develops,  and  death  occurs  in  from  six  to 
eighteen  hours. 

Hydrophobia — morbid  anatomy  :  The  vessels  of  the  brain  and 
cord  are  congested  witli  perivascular  exudation  of  leukocytes 
and  minute  hemorrhages.  These  are  most  intense  in  the 
medulla.  The  pharynx,  larynx,  trachea,  and  bronchi  are 
congested,  and  the  mucous  membrane  of  the  stomach  is  hy- 
perfemic  and  often  covered  with  mucus. 

Diagnosis :  Animals  suspected  to  have  the  disease  should  be 
kept  confined  until  unmistakable  evidences  appear.     When 


372  GENERAL  AND  FUNCTIONAL  DISEASES. 

killed,  the  medulla  should  be  secured  and  rabbits  inoculated 
with  it.  The  occurrence  or  not  of  the  symptoms  in  the  in- 
oculated animal  will  remove  all  doubts. 

Pseudo-hydro'phobia  is  comparatively  common.  It  is  a 
hysterical  outbreak  occurring  in  a  person  several  months 
after  they  have  been  bitten  by  a  dog.  The  symptoms  resem- 
ble somewhat  the  true  disease ;  but  the  temperature  is  not 
elevated  and  the  symptoms  persist  longer  than  do  those  of 
true  hydrophobia.  The  patient  may  bark  like  a  dog,  and  is 
very  emotional  and  talks  about  his  condition. 

The  prognosis  of  hydrophobia  is  fatal.  Inoculation  by 
the  method  of  Pasteur  appears  to  have  an  important  influ- 
ence in  preventing  the  onset  of  the  disease.  The  wound 
should  early  be  excised  or  thoroughly  curetted  and  cauterized. 
A  ligature  may  be  applied  above  the  Avound  and  free  bleeding 
from  it  encouraged.  The  treatment  of  the  developed  disease 
is  the  same  as  that  of  tetanus. 


TETANY. 

Definition :  A  condition  characterized  by  bilateral  tonic 
spasms,  either  paroxysmal  or  continuous,  of  the  extremities, 
and  not  attended  usually  by  loss  of  consciousness. 

Etiology :  It  is  probably  due  to  an  infection.  Debility, 
following  chronic  diarrhoea  or  lactation,  and  rachitis  are  the 
most  common  causes.  It  may  occur  during  pregnancy  or  fol- 
low infectious  fevers.  It  follows  removal  of  the  thyroid 
gland,  and  may  be  associated  with  dilatation  of  the  stomach, 
and  occur  after  the  introduction  of  the  stomach-tube.  In  cer- 
tain parts  of  Europe  it  occurs  epidemically. 

Tetany — symptoms  :  The  attacks  are  commonly  paroxysmal, 
lasting  a  variable  time,  from  a  few  minutes  to  a  few  hours. 
In  the  continuous  cases  the  spasm  may  last  days  or  w'eeks. 
There  may  be  feelings  of  numbness  or  pain  in  the  extremi- 
ties or  a  general  feeling  of  lassitude  for  a  short  time  previous 
to  the  onset  of  the  paroxysm.  In  most  cases  spasms  are 
confined  either  to  the  hands  alone  or  to  the  hands  and  feet. 
The  fingers  are  closely  pressed  together,  the  thumbs  adducted 
and  pressed  either  firmly  against  the  index-fingers  (Minting 
posture),  or  flexed  into  the  palms,  beneath  the  fingers.     The 


TETANY.  373 

hand  itself  and  elbow  are  also  generally  flexed.  In  the 
lower  extremities  the  toes  are  strongly  flexed  and  the  feet  are 
held  in  the  talipes  equino-varus  position.  Ilie  thigh  muscles 
usually  escape.  In  severe  cases  the  muscles  of  the  face  may 
be  involved,  causing  trismus  and  drawing  out  of  the  angles 
of  the  moutli,  Rarely  there  may  be  a  slight  degree  of  opis- 
thotonos and  fixation  of  the  thorax,  with  difficult  respiration, 
which  is  increased  if  the  laryngeal  muscles  are  involved, 
when  the  features  of  laryngismus  stridulus  may  be  present. 
These  consist,  in  the  absence  of  inflammation  of  the  larynx, 
of  arrest  of  respiration,  and  congestion  of  the  face  due  to 
spasm  of  the  laryngeal  muscles,  followed  by  sudden  relaxa- 
tion of  the  muscles,  the  air  being  drawn  into  the  lungs  with  a 
high-pitched  crowing  sound.  It  is  probably  related  to  tetany. 
Unless  the  spasms  are  severe,  there  is  no  pain.  In  cases  due 
to  either  extreme  debility  or  dilated  stomach  there  may  be 
loss  of  consciousness.  Usually  the  mind  is  clear.  The  tem- 
perature during  the  attack  may  be  either  slightly  elevated  or 
subnormal. 

In  the  intervals  between  the  paroxysms  spasms  can  be 
induced  by  a  firm,  continued  pressure  on  the  nerve-trunks 
or  vessels  (Trousseau's  symptom).  A  slight  tap  over  a 
nerve  is  sufficient  to  produce  contractions  of  the  muscles 
supplied  by  it ;  thus,  if  a  slight  tap  is  made  over  the  facial 
nerve,  the  muscles  supplied  by  it  will  be  thrown  into 
contraction  (Chvostek's  symptom).  The  electrical  excit- 
ability of  the  motor  nerves  is  also  increased,  a  weak  cur- 
rent causing  tetanic  contractures  ;  and  we  may  have,  instead 
of  the  normal  formula,  AnClC  or  AnOC  >  KCIC  (Erb's 
symptom). 

The  sensory  nerves  are  also  more  irritable  to  electrical  and 
mechanical  stimulation ;  a  weak  current  or  slight  pressure 
over  such  a  nerve  as  the  supra -orbital  causing  parsesthesia  in 
the  parts  to  which  the  nerve  is  distributed  (Hoffinan's  symp- 
tom). Attacks  may  consist  of  paraesthesia  and  stiffness 
without  spasm. 

Diagnosis :  Tetany  is  distinguished  from  hysteria  by  the 
presence  of  Trousseau's  symptom  and  the  hyperexcitability 
of  the  muscles  which  is  peculiar  to  tetany  alone. 

From  tetanus,  it  is  distinguished  by  the  intermittence  and 


374  GENERAL  AND  FUNCTIONAL  DISEASES. 

milder  degree  of  the  symptoms,  and  the  fact  that  the  spasms 
begin  in  the  extremities,  instead  of  in  the  jaw-muscles. 

The  disease  rarely  causes  death.  It  may  last  from  a  few 
weeks  to  a  few  months.  It  may  recur  each  year  for  a  num- 
ber of  years. 

Tetany — treatment :  The  most  essential  part  of  the  treat- 
ment is  that  of  the  cause.  In  cases  following  removal  of 
the  thyroid,  extract  of  that  gland  should  be  given.  For  the 
attack,  antispasmodics,  as  bromides,  valerian,  hyoscine,  etc., 
may  be  given.  In  severe  cases  inhalations  of  chloroform 
or  morphine  may  be  needed.  Govvers  advises  a  dose  of 
digitalis  at  bedtime  for  the  attacks  that  occur  at  night.  Ice- 
bags  to  the  spine  and  lukewarm  baths  may  also  be  of  service. 


FAMILY  PERIODICAL  PARALYSIS, 

Definition :  A  rare  disease,  of  unknown  pathology,  which 
attacks  members  of  successive  generations  of  a  family,  and  is 
characterized  by  periodical  attacks,  of  a  more  or  less  sudden 
onset,  in  which  there  is  an  extensive,  flaccid,  motor  paralysis, 
associated  with  loss  of  knee-jerk  and  electrical  excitability, 
and  without  sensory  or  psychic  disturbance  of  any  sort. 

Symptoms :  In  the  majority  of  cases  the  attacks  begin  be- 
tween the  ages  of  ten  and  twenty.  In  some  cases  there  are 
prodromata,  as  feelings  of  weariness,  numbness,  or  formica- 
tion, headache,  backache,  sweating,  etc.  The  loss  of  power 
usually  begins  at  night,  and  gradually  progresses  for  a  vary- 
ing period  from  several  hours  to  several  days  before  the 
height  of  the  paralysis  is  reached.  In  most  cases  the  legs 
are  first  affected ;  the  muscles  of  the  body,  arms,  and  neck  in 
severe  cases  becoming  aifected  later.  Involvement  of  the 
cranial  nerves  is  rare.  During  the  attack  there  is  loss  of  the 
knee-jerk,  and  the  electrical  irritability  of  the  muscles  varies 
from  quantitative  decrease  to  absolute  loss  for  both  currents. 
In  the  intervals  between  these  attacks  both  knee-jerk  and 
electrical  irritability  are  normal.  In  some  cases,  during  the 
attack,  cardiac  enlargement,  with  a  mitral  systolic  murmur, 
which  disappears  in  the  normal  intervals,  has  been  reported. 

The  usual  duration  of  the  attack  is  from  ten  to  forty-eight 


MYOTONIA   CONGENITA.  375 

hours,   recovery   of  power   taking   place  gradually.     Treat- 
ment so  far  has  proved  of  no  avail. 

MYOTONIA  CONGENITA  (THOMSONS  DISEASE). 

Definition :  A  rare  disease,  occurring  usually  in  members 
of  different  generations  of  a  family,  characterized  by  rigidity 
or  spasm  of  the  muscles  occurring  when  their  use  is  attempted 
after  a  period  of  rest.  This  rigidity  passes  off  in  a  short 
time,  and  does  not  return  while  the  muscle  is  being  used. 

Etiology :  Heredity  is  the  most  important  factor  in  the 
etiology.  The  affection  is  usually  first  noticed  in  early  child- 
hood.    The  disease  is  rare  in  this  country. 

Symptoms :  The  first  symptom  noticed  is  stiffness  and 
slowness  in  the  movements  of  the  child,  so  that  he  is  unable 
to  take  part  in  games  requiring  rapid  action  of  the  muscles. 
After  a  long  period  of  rest,  the  spasm  may  be  so  intense  that 
any  movement  for  a  time  is  impossible.  After  the  spasm 
passes  off,  the  patient  can  use  the  muscles  as  other  individ- 
uals, until  after  the  next  period  of  rest.  The  legs  are  more 
often  affected  than  the  arms.  The  mechanical  and  electrical 
irritability  of  the  muscle  is  increased.  A  quick  blow  upon  a 
muscle  causes  a  contraction  of  the  fibres,  so  that  a  distinct 
groove  may  last  for  ten  or  fifteen  seconds.  Firm  pressure 
causes  tonic  contraction  of  the  entire  muscle.  The  electrical 
changes,  known  as  the  myotonic  reaction,  have  been  de- 
scribed (see  Electrical  Diagnosis).  The  irritability  of  the 
nerves  is  not  changed.  There  is  no  atrophy ;  if  anythingj 
the  muscles  are  firmer  than  usual. 

No  treatment  seems  to  be  of  service. 


CHAPTER    XV. 

VASOMOTOR  AND  TROPHIC  DISEASES. 

RAYNAUD'S  DISEASE. 

Definition :  Raynaud's  disease,  also  known  as  symmetrical 
gangrene  and  local  asphyxia,  is  a  disorder  characterized  by  a 
local  contraction  of  the  capillaries  (syncope),  followed  by 
congestion  of  the  parts  (asphyxia),  and  sometimes  by  gan- 
grene. 

It  may  occur  in  patients  suffering  from  other  nervous  dis- 
eases, as  tabes,  myelitis,  hysteria,  neurasthenia,  and  insanity. 
It  is  more  frequent  in  adults  between  twenty  and  forty,  but 
may  occur  at  any  age.  A  neuropathic  heredity  and  all  con- 
ditions which  impoverish  the  blood  are  predisposing  causes. 
Syphilis  was  a  cause  in  one  case  reported.  The  most  com- 
mon exciting  cause  is  exposure  to  cold ;  but  fright,  grief, 
fatigue,  trauma,  and  acute  infectious  diseases  may  cause  it. 
It  may  be  associated  with  angio-neurotic  oedema,  urticaria, 
telangiectasis,  and  scleroderma. 

Raynaud's  disease — symptoms:  The  fingers  and  toes  are 
most  frequently  affected ;  but  the  ears,  nose,  or  lips,  and 
patches  of  skin  over  various  parts  of  the  body  may  suffer. 
The  part  becomes  pale,  bloodless,  and  cold,  resembling,  if  in 
the  fingers  or  toes,  those  of  a  dead  person.  The  prick  of  a 
needle  does  not  draw  blood,  and  the  part  feels  numb.  This 
stage  may  last  from  a  few  minutes  to  several  hours,  and  is 
sometimes  attended  with  constitutional  symptoms,  as  chilli- 
ness and  general  discomfort.  The  paroxysm  may  be  con- 
fined to  this  stage ;  or  it  is  succeeded  by  the  stage  of  local 
asphyxia,  in  which  the  part  becomes  congested  and  cyanotic, 
the  blood  returning  slowly  after  pressure,  and  attended  with 
more  or  less  pain.  Less  commonly  the  fingers  become 
bright  red,  hot,  and  covered  with  perspiration.  If  this  stage 
continues  long  enough — several  hours — small  blebs  may  ap- 

376 


RAYNAUD'S  DISEASE. 


377 


pear,  followed  by  ulceratiou,  aud  finally  gangrene  may  de- 
stroy the  part  (see  Fig.  81).  Hemoglobinuria  may  develop 
during  an  attack,  or  take  tlie  place  of  one.  Mental  torpor 
and  transient  loss  of  consciousuess  have  also  occurred  in 
Transient    attacks    of   hemiplegia  liave    been 


some    cases. 


Fig.  81. 


Gangrene  of  fingers  in  Raynaud's  disease  (Dehio). 

reported.  Mania  and  delusions  may  also  be  present.  Periph- 
eral neui'itis  has  also  been  found. 

Pathology :  This  is  obscure.  The  syncope  is  produced  by 
contraction  of  the  vessels ;  the  asphyxia,  upon  dilatation  of 
the  capillaries  and  small  veins,  with  the  persistence  of  some 
degree  of  spasm  in  the  small  arteries. 

Diagnosis :  Raynaud's  disease  can  hardly  be  confounded 
with  anything  else.  Erythromelalgia,  which  most  resembles 
it,  differs  in  the  absence  of  a  stage  of  syncope,  the  non-oc- 
currence of  gangrene,  the  jiresence  of  tenderness,  and  relief 
instead  of  aggravation  of  the  symptoms  by  cold.  A  few 
cases  terminate  fatally.  When  this  does  happen  it  is  usually 
in  children.  Some  cases  recover ;  others  continue  to  have 
attacks  at  varying  intervals  through  life. 


378  VASOAIOTOR  AND   TROPHIC  DISEASES. 

Raynaud's  disease — treatment:  'Diiriug  the  attack  either 
warm  applications  or  wrapping  the  parts  in  cotton- wool 
should  be  employed.  Nitroglycerin  is  a  most  valuable 
remedy.  Measures  to  improve  the  general  health  should 
also  be  employed.  If  gangrene  occur,  surgical  interference 
may  be  necessary. 

ANGIONEUROTIC  (EDEMA. 

Synonyms — definition :  This  disease,  also  known  as  acute 
circumscribed  wdema,  acute  non-inflammatory  oedema,  giant 
urticaria,  periodic  swelling,  Quincke's  disease,  etc.,  is  charac- 
terized by  the  acute  development  of  circumscribed  swellings 
of  the  subcutaneous  or  submucous  tissues  and  commonly 
attended  by  gastro-intestinal  disturbances.  It  may  be  he- 
reditary and  is  often  recurrent.      It  is  a  vasomotor  neurosis. 

Etiology :  Heredity,  disordered  health,  overwork  and  ex- 
haustion are  the  most  important  predisposing  causes.  Many 
of  the  cases  occur  in  neuropathic  subjects  who  suffer  from 
neurasthenia,  hysteria,  or  some  similar  condition.  Most  cases 
appear  in  early  adult  life  ;  but  it  may  occur  at  any  age.  The 
exciting  causes  are  exposure  to  cold,  intestinal  disorders, 
onset  of  puberty,  the  climacteric,  masturbation,  traumatism, 
the  action  of  toxic  agents  such  as  alcohol,  tobacco,  malaria. 
Attacks  are  most  likely  to  occur  between  2  and  6  A.  M.  and 
in  summer  and  winter.  In  some  cases  no  cause  can  be  de- 
termined. 

Symptoms :  The  swellings  generally  appear  without  warn- 
ing and  reach  their  maximum  in  from  one-half  to  two 
hours.  For  a  short  time  before  the  appearance  of  the 
swelling  there  may  be  a  feeling  of  malaise  and  some  gastro- 
intestinal disturbance.  The  parts  usually  affected  are  the 
face,  the  lips,  tongue,  pharynx,  genitals,  and  forehead.  The 
swelling  is  tense,  sharply  defined,  does  not  pit  on  pressure, 
is  not  tender,  and  is  whitish  or  pinkish  in  color.  There  are  a 
feeling  of  tension  and  often  burning  and  itching  sensations. 
The  swelling  lasts  from  a  few  hours  to  several  days,  and 
disa])pears  as  rapidly  as  it  came,  sometimes  succeeded  by 
another  in  a  different  locality.  Scratching  or  rubbing  the 
skin  causes  redness  and  the  formation  of  urticarial  wheals. 
When  the  tongue,  larynx,  and  pharynx  are  affected,  dyspnoea 


PROGRESSIVE  FACIAL   IIKMIATROPHY.  379 

and  difficulty  in  swallowing  are  caused,  and  danger  to  life 
may  result  from  occlusion  of  the  larynx.  Gastro-intestinal 
symptoms  occur  in  about  one-half  the  cases.  They  consist 
of  a  feeling  of  uneasiness  in  the  epigastrium,  distention,  colic, 
nausea,  vomiting,  and  diarrhoea.  The  secretion  of  urine  may 
be  increased,  and  contain  albumin  and  haemoglobin.  An 
eifusion  into  the  joints  may  be  present.  The  attacks  occur 
at  varying  intervals,  and  the  general  health  iu  the  interval  is 
usually  good.  In  some  of  the  congenital  cases  the  swelling 
may  be  permanent. 

Angio-neurotic  oedema — diagnosis — prognosis  :  The  disease 
may  be  confounded  with  the  blue  oedema  of  hysteria  and 
erythema  nodosum.  The  occurrence  of  some  of  the  stigmata 
of  hysteria,  as  paralysis  of  motion  or  sensation,  will  distin- 
guish the  former.  In  the  latter,  the  swellings  are  red  in 
color  and  there  is  tenderness.  The  absence  of  pitting  or 
pressure  distinguishes  it  from  oedema  due  to  cardiac  or  renal 
disease. 

Unless  the  mucous  membrane  of  the  larynx  and  pharynx 
is  attacked,  there  is  no  danger  to  life.  Cases  not  due  to  he- 
reditary taint  frequently  recover. 

Angio-neurotic  oedema — treatment :  This  consists  in  the  re- 
moval of  the  cause,  if  possible,  and  the  use  of  vasomotor  and 
general  tonics.  Strychnine  in  full  doses  is  the  most  useful 
drug.  Atropin,  given  in  full  doses  during  the  attack  and  in 
small  doses  in  the  intervals,  is  also  useful.  These  may  be 
combined  with  the  use  of  mineral  acids,  exercise,  massage, 
and  tonic  baths.  Cold  and  trauma  must  be  especially 
avoided.  If  there  is  an  excess  of  uric  acid  in  the  blood,  the 
diet  must  be  regulated,  and  measures  for  the  relief  of  that 
condition  instituted.  When  either  albuminuria  or  hsemo- 
globinuria  occur,  rest  and  low  diet  should  be  enjoined.  Dur- 
ing the  attack,  dry  heat  may  be  applied  to  the  swellings. 
Morphine  may  be  given  if  there  is  much  pain,  Tracheotomy 
may  be  necessary  when  the  larynx  is  aifected. 

PROGRESSIVE  FACIAL  HEMIATROPHY. 

Definition :  A  rare  disease,  characterized  by  progressive 
wasting  of  one  side  of  the  face. 


380 


VASOMOTOR  AND   TROPHIC  DISEASES. 


Fig.  82. 


Etiology  :  The  disease  is  most  likely  to  occur  in  neuropathic 
individuals.  It  usually  develops  between  the  ages  of  ten  and 
twenty.  Direct  heredity  has  been  traced  in  a  few  cases. 
Injury  to  the  side  of  the  face,  exposure  to  cold,  and  the  infec- 
tious fevers  may  act  as  exciting  causes.  It  also  occurs  with 
disease  of  the  hfth  nerve  and  in  people  who  have  some  other 
nervous  disease,  as  hysteria,  epilepsy,  tabes,  multiple  sclerosis, 
syringomyelia,  and  insanity.  It  may  be  impossible  to  trace 
any  cause. 

Facial  hemiatrophy — symptoms:  The  disease  first  shows 
itself  in  patches  and  progresses  gradually.  The  skin  grows 
thinner,  there  is  loss  of  pigment,  and  the  hair  falls  out.  At 
first  the  spots  are  white  in  color,  but  as  they  grow  larger 

they  become  of  a  yellowish  tinge. 
As  the  skin  and  subcutaneous  fat 
atrophy,  pits  or  trough-like  de- 
pressions are  formed.  The  bones, 
and,  to  a  slight  degree  the  mus- 
cles, are  also  involved.  The  se- 
baceous glands  also  atrophy  and 
their  secretion  becomes  checked. 
Perspiration  is  either  normal  or 
increased.  The  atrophy  may  in- 
volve the  tongue,  hard  and  soft 
palate,  the  gums  (with  falling  out 
of  the  teeth),  and  the  uvula.  Neu- 
ralgic pains  and  parsesthesise  may 
occur  in  the  early  stages  of  the 
disease.  Rarely,  there  may  be 
anaesthesia.  Spasm  of  the  mas- 
seter,  buccinator,  and  temporal 
muscles  is  a  rare  symptom. 
When  the  disease  is  fully  de- 
veloped the  atrophied  side  is 
separated  from  the  other  by  a  deep  groove  ;  the  skin  has  a 
roughened  and  puckered  appearance  ;  the  hair  of  the  head, 
beard,  eyebrows,  and  lashes  has  fallen  out  in  patches ;  the 
eyeball  is  sunk  in  and  the  palpebral  fissure  narrowed  (Fig.  82). 
Pathology — diagnosis — prognosis — treatment:  There  has 
been  found  a  degenerative   neuritis    involving  the  branches 


Case  of  facial  hemiatrophy  (after 
Yonge). 


SCLERODERMA.  381 

of  the  trigeminus,  most  marked  in  the  superior  maxilkuy 
branch,  and  also  atrophy  of  the  ascending  root  of  the  fifth 
nerve. 

The  disease  might  be  confomided  with  congenital  asym- 
metry and  morphoea.  The  former  is  noticed  soon  after  birth, 
and  remains  stationary.  The  latter  is  considered  in  another 
place  (p.  382). 

The  disease  does  not  shorten  life,  but  its  progress  cannot 
be  arrested  by  any  known  method  of  treatment.  Tonics  and 
galvanism  may  be  tried. 

FACIAL  HEMIHYPERTROPHY. 

This  is  an  extremely  rare  condition,  in  which  one  side  of 
the  face  jprogressively  enlarges.  Care  must  be  taken  in  this 
affection  not  to  mistake  the  normal  side  for  one  that  is  atro- 
phied ;  in  other  words,  the  condition  may  thus  be  mistaken 
for  facial  hemiatrophy. 

SCLERODERMA. 

Definition :  This  is  a  disease  resulting  in  a  diffuse  or  cir- 
cumscribed atrophy  and  induration  of  the  skin  and  subcu- 
taneous tissue.  When  the  disease  is  circumscribed  it  is 
commonly  known  as  morphoea,  or  Addison's  keloid. 

Etiology  :  The  disease  most  commonly  occurs  in  females. 
It  may  occur  at  any  age.  It  may  follow  infectious  diseases, 
exposure  to  extremes  of  temperature,  trauma,  mental  and 
physical  strain,  and  may  also  occur  in  those  suffering  from 
some  other  nervous  disease. 

Scleroderma — symptoms :  Pain  in  the  joints  or  extremities 
may  precede  for  a  time  the  involvement  of  the  skin.  This 
is  first  noticed  as  a  feeling  of  stiffness,  most  commonly  felt 
at  the  back  of  the  neck,  the  shoulders  and  arms,  the  face 
and  scalp.  The  disease  progresses  slowly,  and  wdien  the 
induration  has  reached  its  height  the  skin  of  the  affected 
area  is  of  leather-like  thickness.  It  cannot  be  pinched  uj), 
nor  can  pitting  be  produced  by  pressure.  If  tiie  skin  over 
a  point  is  involved,  this  becomes  fixed  as  the  skin  becomes 
rigid.     The  face,  if  affected,  loses  all  traces  of  expression  ; 


382  VASOMOTOR  AND   TROPHIC  DISEASES. 

masticatiou  may  be  difficult.  Respiration  may  be  interfered 
with  if  the  skin  of  the  chest  is  involved.  If  there  is  wide- 
spread involvement,  the  patient  is  in  a  state  of  more  or  less 
complete  rigidity  ;  in  fact,  as  if  he  were  encased  in  leather. 
The  line  of  demarcation  between  the  affected  and  the  sound 
skin  is  not  a  sharp  one.  The  color  of  the  skin  is  usually  white, 
but  may  be  mottled  or  pigmented.  The  mucous  membrane  of 
the  mouth,  vagina,  etc.,  may  be  affected.  The  secretions  of 
the  skin  are  diminished  or  absent.  Vasomotor  disturbances, 
as  cyanosis  of  the  legs  and  hands,  are  common.  After  the 
disease  has  lasted  a  time,  atrophy  of  the  subcutaneous  tissues 
occurs  and  deformities  result.  That  known  as  sclerodactylie 
consists  of  deformity,  shortening,  and  atrophy  of  the  fingers, 
with  thickening  and  rigidity  of  the  skin,  which  is  either 
waxy  in  color  or  pigmented. 

Morphoea  presents  itself  in  the  form  of  patches,  bands,  or 
streaks  of  various  size.  They  are  especially  apt  to  occur 
on  the  breast  and  in  the  course  of  the  fifth  nerve.  The 
patches  are  white  or  yellowish-white  in  color,  bordered  by 
a  pinkish  zone.  In  general  characteristics  they  resemble  the 
patches  in  the  diffuse  form,  but  the  rigidity  may  not  be  so 
marked.  It  not  infrequently  is  complicated  by  Raynaud's 
disease. 

The  pathology  of  scleroderma  is  unknown.  Changes  in 
the  bloodvessels  of  the  skin  and  increase  of  connective  tissue 
have  been  found.  The  thyroid  has  been  found  atrophied. 
Mor])hffia  may  be  confounded  with  facial  hemiatrophy.  All 
the  tissues  in  the  latter  are  affected  primarily ;  in  the  former 
the  subcutaneous  tissues  only  atrophy  from  pressure. 

Prognosis :  In  the  early  stages  recovery  may  occur.  In 
cases  of  long  standing  this  does  not  result.  The  disease 
itself  does  not  produce  death.  It  predisposes  to  affections 
such  as  rheumatism  and  pneumonia,  which  are  apt  to  be 
fatal. 

Scleroderma — treatment :  The  patient  should  be  warmly 
clad,  and  guarded  against  exposure.  Tonics  and  nutrients, 
as  arsenic  and  cod-liver  oil,  should  be  given.  Warm  baths, 
followed  by  frictions  of  oil,  are  valuable.  Thyroid  extract 
may  be  tried.  Good  results  have  been  claimed  from  large 
doses  of  salol  (gr.  xv,  three  times  daily). 


ACROMEGALY. 


383 


ACROMEGALY. 

Definition :  A  disease  cliaracterized  by  overg;rowth  of  cer- 
tain parts,  chiefly  in  the  bones  of  the  face  and  extremities. 

Etiology  :  It  most  frequently  develops  between  the  ages  of 
twenty  and  forty-tive.  Trophic  disturbances,  causing  en- 
largement of  certain  parts  (as  one  limb),  may  occur  in  syrin- 
gomyelia and  tabes.  The  development  of  the  disease  has  not 
been  connected  with  any  well-established  cause.  The  disease 
seems  to  be  associated  ^^■ith  disease  of  the  })ituitary  body. 

Acromegaly — symptoms  :  The  symptoms  of  the  disease  de- 
velop gradually.     Among  early  symptoms  may  be  noted  a 

Fig.  S3. 


Hand  in  acromegaly  (Osborne). 


feeling  of  weakness,  apathy,  frontal  headache,  pain,  and  par- 
sesthesia  in  the  extremities.  In  women,  menstruation  becomes 
irregular.  There  may  be  loss  of  sexual  power  and  appetite. 
Disinclination  for  exertion  and  depression  of  spirits  are  also 
early  symptoms.     Vasomotor  symptoms,  as  hyperidrosis  and 


384 


VASOMOTOR  AND   TROPHIC  DISEASES. 


polyuria,  may  also  be  noticed  at  this  time.  Soon  it  will  be 
noticed  that  the  hands,  feet,  and  face  are  increasing  in  size, 
while  the  stature  is  growing  less. 

When  the  disease  is  developed,  with  some  of  the  symp- 
toms above  mentioned,  the  hands  will  be  found  to  be  con- 


FiG.  84. 


Case  of  acromegaly,  showing  fac  lal 


ion  (Dercum). 


siderably  and  symmetrically  enlarged,  all  the  tissues  being 
hypertrophied.  The  tingers  are  sausage-shaped,  and  the  nails 
small,  flat,  and  longitudinally  striated.  The  general  shape 
of  the  hand  resembles  that  of  a  spade  (Fig.  83). 

The  wrists  are  enlarged  and  the   lines  in  the   palms  are 


ACROMEGALY. 


385 


Fig.  85. 


deej)ened.  The  changes  in  the  feet  are  similar.  The  great 
toe  is  often  enkirgt^l  out  of  proportion  to  the  rest  of  the  foot, 
and  the  os  calcis  projects  backward. 

The  lower  jaw  is  markedly  increased  in  size  and  projects  for- 
ward. The  lips  are  large,  particularly  the  lower  one.  The  nose 
is  also  enlarged,  and  often  pig- 
mented ;  and  the  tongue,  palate, 
and  alveolar  processes  are  like- 
wise hypertrophied.  The  supra- 
orbital arches  are  thickened,  in 
some  cases  causing  the  eyes  to 
appear  deeply  set ;  in  others 
there  is  exophthalmos.  The 
malar  bones  and  zygoma  stand 
out  prominently.  The  ears  are 
enlarged,  the  hair  coarse  and 
dry,  and  the  beard  scanty.  The 
skin  of  the  face  is  also  dry,  and 
may  be  pigmented.  The  expres- 
sion is  dull  and  rather  sad  (see 
Fig.  84). 

The  bones  forming  the  thorax 
also  increase  in  size,  and  the 
back  becomes  bent  (kyphosis) 
(Fig.  85). 

The  external  genitals  in  both  sexes  may  be  enlarged.  The 
uterus  is  small,  presenting  the  changes  incident  to  senile  invo- 
lution. Contracted  visual  fields  and  hemianopsia,  and  vary- 
ing degrees  of  optic  neuritis  and  atrophy,  have  been  reported. 
Nystagmus  and  paralysis  of  the  ocular  muscles  may  also 
occur.  After  the  disease  has  lasted  for  some  time,  the  mus- 
cles become  soft  and  flabby. 

The  viscera  are  usually  normal.  Albumin  may  be  found 
in  the  urine,  which  is  increased  in  quantity.  The  thyroid 
may  be  enlarged.  The  voice  is  low  pitched,  resonant,  and 
of  a  disagreeable  intonation.  Speech  may  be  difficult,  on 
account  of  the  enlarged  tongue. 

Acromegaly — morbid  anatomy  and  pathology :  Changes  in 
the  pituitary  (/land  have  been  noted,  tumor,  cyst,  hypertrophy, 
etc.     In  some  cases  the  thyroid  gland  has  been  found  also 

25— N.  D. 


Case  of  acromegaly  (Osborne) 


386  VASOMOTOR  AND   TROPHIC  DISEASES. 

diseased — i.  e.,  cystic,  hypertrophied,  or  atrophied.  The  en- 
largement of  the  bones  is  a  true  hypertrophy,  the  increase 
taking  place  from  the  periosteum.  The  changes  are  probably 
due  to  interference  in  some  way,  Avith  the  functions  of  the 
pituitary  gland. 

Diagnosis :  Acromegaly  must  be  differentiated  from  hyper- 
trophic pulmonary  arthropathy,  leontiasis  ossea,  myxcedema, 
adiposis  dolorosa  elephantiasis,  osteitis  deformans,  and  local 
hypertrophies.  The  points  of  distinction  between  acromeg- 
aly and  the  first  four  diseases  given,  will  be  mentioned  under 
the  description  of  those  disorders. 

In  elephantiasis  the  thickening  and  increase  in  size  are  usu- 
ally localized,  and  are  confined  to  the  skin  and  connective  tis- 
sue. In  osteitis  deformans,  or  Paget's  disease,  the  increase 
in  bone-tissue  is  most  marked  in  the  cranial  bones,  not  those 
of  the  face ;  and  the  long  bones  which  may  become  curved 
and  misshaped.  The  shape  of  the  face  is  triangular  with  the 
base  upward,  while  in  acromegaly  it  is  egg-shaped,  with  the 
large  end  downward.  The  general  involvement  differentiates 
acromegaly  from  local  hypertrophies. 

Prognosis :  The  disease  is  incurable,  and  terminates  in 
death,  either  from  exhaustion,  suicide,  or  intercurrent  disease. 
The  duration  is  from  ten  to  twenty  years. 

Treatment  is  symptomatic.  Extract  of  pituitary  gland  may 
be  tried. 

HYPERTROPHIC  PULMONARY  OSTEOARTHROPATHY. 

Definition :  This  affection  is  characterized  by  enlargement 
of  the  hands  and  feet,  and  of  the  ends  of  the  long  bones. 

Etiology :  The  disease  is  nearly  always  associated  with  some 
long-standing  chronic  disease,  especially  of  the  bronchi,  lungs, 
or  pleurse.  A  few  cases  have  apparently  been  due  to  syphilis. 
The  disease  has  been  thought  to  be  due  to  the  absorption  of 
toxic  substances,  which  exercise  an  irritant  action  upon  the 
bones  and  articular  structures. 

Symptoms :  The  hypertrophy  of  the  long  bones  is  confined 
to  the  lower  three-fourths.  The  phalangeal,  metacarpal,  and 
metatarsal  bones  are  also  increased  in  size  and  club-shaped. 
The  nails  are  large  and  curved  over  the  ends  of  the  phalanges. 


LEONTIASIS  OSSEA. 


387 


The  face  and  head  escape.     There  is  often  pain,  and  effusions 
into  the  joints  occur. 

Diagnosis :  Thayer  tabulates  the  features  which  distinguish 
this  disease  from  acromegaly,  as  follows  : 


Acromegaly. 

Subjective  symptoms;  headache; 
ocular  disturbances.  General  ner- 
vous manifestations;  sweating,  poly- 
dipsia, etc. 

Predominance  of  facial  changes. 

Changes  mainly  in  soft  parts. 

Changes  in  the  bones  are  generally 
the  indication  of  an  abnormal  growth  ; 
and  while  inflammatory  changes 
(periostitis)  maybe  present,  they  are 
rare,  and  are  usually  limited  to  the 
points  of  muscular  and  tendinous  at- 
tachment and  the  epiphyses,  result- 
ing in  a  general  plumpness  of  the 
bone,  with  an  exaggeration  of  the 
normal  irregularities. 

Fingers  flat  and  expanded  later- 
ally ;  nails  relatively  small. 

Absence  of  joint-symptoms. 

Onset  without  apparent  cause. 

Changes  in  the  peripheral  nerves 
are  common. 

Tumor  or  disease  of  the  pituitary 
body  usual ;  goitre  frequent. 


Osteo-arthropathy. 

Pain  in  joints  of   the   extremites 
only. 


Absence  of  facial  changes. 

No  changes  in  soft  parts. 

Characteristic  periostitis,  limited 
usually  to  the  lower  parts  of  the  diaph- 
yses  of  the  long  bones  of  the  ex- 
tremities, resulting  in  marked  thick- 
ening and  deformity  of  the  bone. 


Fingers  clubbed ;  nails  large  and 
incurved. 

Presence  of  joint-symptoms. 

Secondary  to  some  chronic,  usually 
pulmonary,  affection. 

Changes  in  the  peripheral  nerves 
are  rare. 

Neither  pituitary  tumor  nor  goitre. 


The  course  of  the  disease  depends  upon  that  causing  it. 
does  not  end  fatally  of  itself. 

The  treatment  is  that  of  the  primary  aflFection. 


It 


LEONTIASIS  OSSEA. 

Leontiasis  ossea  is  a  rare  affection,  beginning  frequently  in 
early  life,  often  as  a  result  of  trauma,  in  which  there  is  hyper- 
ostosis of  the  cranial  bones,  and  sometimes  of  those  of  the  face. 
The  soft  tissues  may  also  be  affected.  The  restriction  of  the 
hypertrophy  to  the  bones  of  the  head  and  face  suffices  to  dis- 
tinguish the  affection  from  acromegaly. 


388  VASOMOTOR  AND  TROPHIC  DISEASES. 

EXOPHTHALMIC  GOITRE. 

Synonyms — etiology  :  This  disease  is  also  known  as  Parry's 
disease,  Graves's  disease,  and  Basedow's  disease.  It  is  more 
frequent  in  women  than  in  men.  Most  cases  develop  between 
the  twentieth  and  thirtieth  years.  Worry,  fright,  and  de- 
pressing emotions  often  precede  the  development  of  the  dis- 
ease.    It  has  occurred  in  several  members  of  the  same  family. 

Exophthalmic  goitre — symptoms :  The  disease  may  be  acute 
or  chronic.  The  former  is  rare.  It  would  be  characterized 
by  sudden  development  of  the  symptoms  and  a  rapid  course 
of  the  disease.  In  a  case  reported  by  J.  H.  Lloyd  death  oc- 
curred in  three  days. 

More  commonly  the  onset  is  gradual  and  the  course 
chronic.  The  prominent  symptoms  of  the  disease  are  tachy- 
cardia, exophthalmos,  enlargement  of  the  thyroid,  and  tremor. 

An  early  symptom  is  the  increased  rapidity  of  the  heart's 
action,  which  is  extreme,  reaching  in  some  cases  160  or  more. 
The  action  is  usually  regular.  Tlie  area  of  cardiac  pulsation 
is  visibly  increased,  and  the  heart's  action  is  strong  and  the 
sounds  loud.  The  large  arteries  at  the  root  of  the  neck  can 
be  seen  to  throb.  The  capillary  pulse  can  be  readily  seen,  as 
can  also  at  times  a  venous  pulse  in  the  veins  of  the  hand. 
On  auscultation,  murmurs  are  usually  heard  at  the  base  and 
apex  and  over  the  sternum. 

The  exophthalmos  follows  the  vascular  disturbance.  It 
may  be  unilateral,  but  usually  is  bilateral.  The  eyes  pro- 
trude, so  that  the  lids  do  not  completely  cover  the  sclerotics, 
showing  a  streak  of  white  between  the  lid  and  cornea.  The 
palpebral  fissure  is  increased  in  width  (Stellwag's  sign).  In 
some  cases,  wlien  the  eye  is  made  to  look  down  the  lid  does 
not  follow  it,  as  in  health  (von  Graefe's  sign).  The  patients 
wink  less  frequently  than  in  health.  The  vision  is  normal, 
and  there  are  usually  no  pupillary  changes.  Exo]ihthnlmos 
may  sometimes  be  very  slight  in  degree.  The  enlargement 
of  the  thyroid  generally  develops  at  about  the  same  time  as 
the  exophthalmos.  One  lobe  only  or  the  entire  gland  may 
be  affected.  The  gland  pulsates,  a  thrill  may  be  felt  on  pal- 
pation, and  either  a  systolic  or  double  murmur  heard  on 
auscultation. 


MYXCEDEMA.  389 

The  tremor  is  fine,  and  increased  by  exertion.  Other 
symptoms  common  to  the  disease  are  anaemia,  loss  of  flesh, 
vomiting  (which  may  be  persistent),  diarrhoea,  some  elevation 
of  temperature,  ])hysical  weakness,  and  mental  depression 
and  irritability.  There  may  also  be  flushes  of  heat  and  pro- 
fuse perspiration.  Pigmentation  of  the  skin,  urticaria,  and 
cedema  may  occur.  Sugar  or  albumin  may  be  found  in  the 
urine. 

Pathology — diagnosis — prognosis  :  The  disease  is  probably 
due  to  disturbance  of  the  function  of  the  thyroid  gland,  most 
likely  an  over-secretion. 

The  prominent  symptoms  make  the  diagnosis  clear.  In 
the  early  stages  the  disease  may  be  mistaken  for  neurasthenia. 

Prognosis :  The  disease  may  cause  death.  The  course  is 
chronic,  and  it  may  last  years.     Cure  may  take  place. 

Exophthalmic  goitre — treatment :  Rest  and  freedom  from 
mental  worry  or  excitement  are  important.  For  the  tachy- 
cardia an  ice-bag  over  the  heart  is  most  useful.  The  tincture 
of  strophanthus  or  of  digitalis  may  also  assist  in  reducing  the 
rapidity  of  the  heart.  Belladonna,  given  until  its  constitu- 
tional effects  are  manifested,  is  of  service.  Electricity  may 
help,  the  cathode  being  placed  at  the  back  of  the  neck  and 
the  anode  over  the  heart,  and  a  constant  current  employed. 
Cures  have  recently  been  reported  from  the  use  of  the  extract 
of  suprarenal  gland,  and  H.  C.  Wood  has  had  good  results 
from  extract  of  spleen.  If  ansemia  is  present,  iron  must  be 
given.  In  extreme  cases  part  of  the  thyroid  may  be  removed, 
or,  what  has  recently  been  reported  to  give  good  results,  the 
cervical  sympathetics  may  be  divided. 


MYXCEDEMA. 

Definition :  A  disease  dependent  upon  atrophy  of  and  con- 
sequent loss  of  function  of  the  thyroid  gland,  and  characterized 
by  a  myxoedematous  condition  of  the  subdermal  tissues  and 
progressive  mental  failure. 

Etiology ;  It  is  more  frequent  in  men  than  in  women,  and  is 
commonly  a  disease  of  middle  life.  It  has  occurred  after 
acute  articular  rheumatism,  erysipelas,  and  persistent  hemor- 


390  VASOMOTOR  AND  TROPHIC  DISEASES. 

rhages.  Syphilis  has  apparently  been  the  cause  in  some 
cases. 

Myxoedema — symptoms:  Usually  the  onset  and  course  of 
the  disease  are  slow.  Rarely  the  disease  may  be  acute,  as  in 
the  case  described  by  Osier,  in  which  there  was  a  rather  rapid 
development  of  the  symptoms,  associated  with  enlargement 
of  the  thyroid,  these  symptoms  disappearing  in  a  few  months. 
There  is  a  firm,  inelastic  swelling  of  the  skin,  which  does 
not  pit  on  pressure,  most  marked  on  the  face  and  limbs. 
It  is  also  dry  and  rough,  there  is  absence  of  perspiration,  and 
scaly  particles  of  epithelium  brush  off.  The  hair  is  dry  and 
brittle ;  and  the  nails  brittle,  striated,  and  either  atrophied  or 
thickened.  In  the  supraclavicular  and  axillary  regions  are 
tumor-like  swellings.  The  physiognomy  is  characteristic,  the 
features  being  coarse  and  broad,  the  lips  thick,  the  nostrils 
broad  and  thick,  and  the  mouth  enlarged  (Fig.  86).  The 
color  of  the  skin  is  yellowish-white,  and  over  each  cheek,  and 
sometimes  on  the  nose,  is  a  reddish  patch. 

There  is  slowness  of  thought  and  movement,  the  memory 
fails,  the  patient  becomes  irritable  and  suspicious,  and  finally 
hallucinations,  delusions  (with  either  maniacal  or  melancholic 
symptoms)  may  result.  Speech  is  slow  and  difficult.  The 
bodily  temperature  is  below  normal,  97°-97.5°  F.  A  feeling 
of  coldness  is  common.  Albuminuria,  and  rarely  glycosuria, 
may  be  present.  Casts  may  also  be  found.  Myxoedema 
may  follow  exophthalmic  goitre. 

Pathology :  Symptoms  similar  to  those  described  above  are 
caused  by  removal  of  the  thyroid  gland.  In  cases  of  idio- 
pathic myxoedema  the  thyroid  is  always  found  to  be  atrophied, 
and  may  be  converted  into  a  fibrous  mass.  To  the  loss  of 
function  of  this  gland  the  symptoms  are  due. 

Myxoedema — diagnosis  :  The  fact  that  the  swelling  does  not 
pit  on  pressure  and  is  not  influenced  in  location  by  gravita- 
tion distinguishes  the  disease  from  oedema  due  to  cardiac, 
kidney,  or  liver  disease.  The  features  that  distinguish  it 
from  adiposis  dolorosa  wall  be  mentioned  under  that  heading. 

The  prognosis  is  hopeful,  but  death  may  occur  from  the 
disease  itself  or  from  phthisis  or  renal  or  cerebral  disease. 

Myxoedema — treatment :  The  one  remedy  for  this  condition 
is  thyroid  gland,  preferably  in  the  form  of  the  dried  and 


CRETINISM. 


391 


powdered  gland  or  of  the  glycerin  extract.  Of  the  former,  a 
commencing  dose  is  one  grain  three  times  daily,  which  is  in- 
creased until  five  grains  three  times  daily  is  being  taken ;  or 
restlessness,  delirium,  and  rapid  pulse  ensue,  when  the  dose 
must  be  reduced.  After  the  symptoms  have  disappeared, 
small  doses  of  the  gland  should  be  continued  indefinitely. 
The  patient  should  also  be  kept  warm,  and,  if  possible,  move 
to  a  warm  climate  during  the  winter  months. 

CRETINISM. 

Definition :  This  is  a  condition  due  to  an  absence  or  loss  of 
function  of  the  thyroid  gland,  which  is  either  congenital  or 
appears  at  any  time  before  puberty. 

Two  forms  are  recognized,  the  sporadic  and  the  endemic.  In 
the  former  the  gland  may  be  congenitally  absent.  Tlie  con- 
dition may  develop  with  goitre,  or  the  gland  may  atrophy 
after  one  of  the  specific  fevers. 

Symptoms :  The  child  does  not  grow  as  it  should,  nor  does 


A  cretin,  aged  about  thirty-live  years  (Piiilacielphia  Hospital). 


392 


VASOMOTOR  AND   TROPHIC  DISEASES. 
Fig.  87. 


Cretin ;  same  case  as  shown  in  Fig. 


it  develop  mentally.  The  tongue  is  large  and  hangs  out  of 
the  mouth.  The  general  appearance  of  the  skin  and  features 
is  as  described  under  myxoederaa.  The  abdomen  is  swollen. 
A  cretin  of  adult  age  may  resemble  in  stature  and  mentality 
a  child  of  two  or  three  (Figs.  86  and  87)  years.  Endemic 
cretinism  is  met  with  in  Switzerland  and  in  parts  of  Italy 
and   France. 

The  treatment  is  similar  to  that  advised  in  myxcedema. 

ADIPOSIS  DOLOROSA. 

Under  this  title  Dercum  has  described  a  disease  occurring 
in  adults,  characterized  by  the  deposition  of  fat  in  various 


ADIPOSIS  DOLOROSA. 


393 


parts  of  the  body,  which  is  first  in  the  form  of  bunches  or 
nodules,  and  later  is  uncircumscribed  and  attended  with  pain, 
diminished  cutaneous  sensibility,  and  great  muscular  weak- 
ness (Fig.  88).     Cases  have  also  been  observed  by  F.  P. 


Fig.  88. 


Adiposis  dolorosa  (Dercum). 

Henry,  Peterson,  Loveland,  Ewald,  Spiller,  and  Eshner — 
thirteen  in  all.  There  is  frequently  a  history  of  either  alco- 
holism or  syphilis. 

It  differs  from  myxcedema  in  the  freedom  from  changes  in 
the  face,  hands,  and  feet,  and  the  absence  of  marked  mental 
symptoms. 

Eshner  recommends  the  use  of  thyroid  gland  and  massage. 


MENTAL  DISEASES. 


GENERAL  CONSIDERATIONS. 

A  PERSON  suffering  from  mental  disease,  or  derangement 
of  the  higher  faculties  of  the  mind,  is  commonly  said  to  be 
insane.  Scientifically  speaking,  however,  all  such  are  not 
insane,  as  will  be  seen.  Hence  mental  diseases  will  be  treated 
under  two  heads — viz.,  Insanity  and  Idiocy. 

Many  definitions  of  insanity  have  been  given  by  different 
authorities.  None  is  entirely  satisfactor3\  One  of  the  sim- 
plest, and  which  covers  the  ground  as  well  as  any,  is  that 
of  H.  C.  Wood  :  Insanity  is  a  condition  of  mental  aberration 
sufficiently  intense  to  overthrow  the  normal  relation  of  the 
individual  to  his  own  thoughts  and  acts,  so  that  he  is  no 
longer  able  to  control  them  through  the  will.  This  definition 
would  also  include  coma,  due  to  apoplexy,  drugs,  etc. ;  and 
deliriums  due  to  toxaemias  (infectious  diseases,  poisons) ; 
which,  while  conditions  of  mental  aberration,  are  not  com- 
monly considered  as  forms  of  insanity. 

From  the  above  definition,  it  will  be  seen  that,  to  exhibit 
symptoms  of  insanity,  there  must  be  a  departure  from  a 
previous  normal  state.  Therefore,  to  determine  the  sanity 
or  insanity  of  an  individual,  we  must  discover  if  there  has 
been  a  marked  change  in  the  former  habits  of  the  individual. 
According  to  this,  idiocy  and  imbecility  are  not  forms  of  in- 
sanity. 

Idiocy,  as  defined  by  Ireland,  is  "  mental  deficiency  or  ex- 
treme stupidity,  depending  upon  malnutrition  or  disease  of 
the  nervous  centres,  occurring  either  before  birth  or  before 
the  evolution  of  the  mental  faculties  in  childhood.^' 

The  word  imbecility  is  used  to  denote  a  less  decided  degree 
of  mental  incapacity.  The  term  feeble-minded  is  also  used  to 
denote  these  conditions. 

395 


396  MENTAL  DISEASES. 

Heuce,  according  to  this  definition,  an  idiot  or  imbecile 
who  from  birth  has  been  deficient  mentally,  is  not,  strictly 
speaking,  insane.  He  might  become  so  later;  but  such  would 
have  to  be  decided  by  the  same  tests  as  are  applied  to  those 
who  were  previously  mentally  healthy — i.  e.,  a  departure  from 
a  previous  standard.  Thus,  if  an  idiot  who  had  always  been 
quiet  suddenly  became  noisy  and  violent,  or  developed  delu- 
sions and  hallucinations,  Ave  could  say  that  he  had  become 
insane. 

Stigmata  of  degeneration :  By  degeneration  we  mean  a 
marked  and  morbid  deviation  from  the  normal  type.  It  is 
shown  by  a  faulty  or  unbalanced  development  of  the  body,  and 
by  nervous  and  mental  peculiarities  constituting  the  so-called 
neuropathic  state.  These  peculiarities  are  termed  the  stig- 
mata of  degeneration.  The  more  important  of  these  are  as 
follows  : 

Anatomical  stigmata :  Creinial  anoinalles :  consisting  of 
asymmetry  of  the  cranium,  microcephalus,  peculiar  shapes 
of  the  skull.  Facial  asymmetry,  as  excessive  prognathism, 
large  jaws. 

Deformities  of  the  palate  and  uvula. :  as  the  torus  palatinus 
— i.  e.,  a  projecting  ridge  or  suture  along  the  palatine  suture ; 
high,  narrow,  and  asymmetrically  arched  palates. 

Anomcdies  of  the  teeth :  as  macrodontism  ;  microdontism  ; 
projecting  teeth  ;  badly  placed  or  misplaced  teeth ;  double 
row  of  teeth,  teeth  striated  longitudinally  or  transversely. 

Anowallex  of  the  tongue  avd  lips :  as  macroglossiis,  micro- 
glossus,  and  asymmetry  of  the  two  halves. 

Anom.cdies  of  the  eyes :  as  narrow  palpebral  fissure ;  muscu- 
lar insufiiciency ;  marked  astigmatism,  and  nystagmus. 

Anomcdies  of  the  ears:  abnormally  implanted  ears — i.  e., 
they  project  too  far  or  lie  too  closely ;  are  placed  too  high  or 
too  low ;  too  far  forward  or  too  far  backward  on  the  head. 
Excessively  large  ears — /.  e.,  absolutely  too  large  or  relatively 
too  large.  Ears  which  are  too  small.  Ears  that  have  a  gen- 
eral ugly  shape ;  that  are  markedly  conchoidal  in  shape ; 
those  in  which  the  lobes  are  absent  or  adherent  to  the  cheek  ; 
abnormalities  in  or  absence  of  the  development  of  the  helix, 
antihelix,  and  other  parts  of  the  external  ear. 

Anomalies  of  the  limbs:  as  congenital  luxations;  supernu- 


INSANITY.  397 

merary  fingers  or  toes ;  fusion  of  fingers  or  toes ;  missing 
fingers  or  toes ;  excessive  relative  length  of  the  arms,  etc. 

Anomalies  and  malformations  of  the  genital  organs. 

Anomalies  of  the  skin :  as  excessive  hairiness  or  absence  of 
hair. 

The  peculiarities  of  the  palate  and  ear  are  the  most  im- 
portant. 

Any  of  these  stigmata  singly  may  occur  in  apparently 
normal  individuals  ;  but  when  several  are  present  in  the  same 
individual,  or  when  combined  with  other  peculiarities  abont 
to  be  mentioned,  they  are  significant. 

Physiological  stigmata  :  Tremor ;  tics  ;  nystagmus  ;  heredi- 
tary defects  in  the  muscular  system  leading  to  atrophies ;  ex- 
cessive or  defective  sensibility  of  the  cutaneous  and  special 
senses ;  defects  in  speech ;  perversions  of  the  sexual  and 
other  instincts ;  a  diminished  power  of  resistance  to  nervous 
and  emotional  strains. 

Mental  stigmata:  These  include  excessive  egotism,  emo- 
tionalism, eccentricities,  etc. 

Hsematoma  auris  is  due  to  an  effusion  of  blood  or  bloody 
serum  between  the  cartilage  of  the  ear  and  its  perichondrium. 
It  causes  a  swelling  of  the  cartilaginous  portions  of  the  ear, 
usually  of  the  helix.  It  most  often  occurs  in  the  chronic 
forms  of  insanity,  especially  paretic  dementia  and  epileptic 
insanity,  and  may  appear  suddenly  without  obvious  cause. 
It  also  occurs  in  the  sane,  due  to  traumatism. 

INSANITY. 

General  Considerations. 

The  various  forms  by  which  insanity  is  manifested  are  not 
diseases,  although  for  convenience  they  are  spoken  of  as  such, 
but  are  symptom  groups.  To  the  various  components  of 
these  groups  terms  have  been  applied  which  must  be  under- 
stood before  an  intelligent  idea  of  the  groups  themselves  can 
be  attained. 

We  speak  of  the  emotional  nature  being  exalted,  depressed, 
or  perverted. 

The  exaltation  may  be  confined  either  to  emotions,  which 


398  MENTAL  DISEASES. 

are  normally  "exalted,"  such  as  joy,  anger,  etc.,  as  in  mama; 
or  to  the  "  depressive  "  emotions,  as  sorrow,  fear,  etc,  as  in 
melanGliolia  ;  or  there  may  be  alternation  of  these  conditions, 
as  in  circular  insanity. 

A  condition  of  true  emotional  enfeeblement  or  lethargy,  in 
which  stimuli  which  would  naturally  affect  this  or  that  emo- 
tion, make  no  impression,  occurs  in  advanced  dementia.  This 
condition  must  be  distinguished  from  melancholia,  which,  as 
has  been  already  stated,  is  not  due  to  depression  of  the  emo- 
tional nature,  but  to  exaltation  of  the  depressive  emotions. 

Depression  of  the  emotions  may  also  be  simulated  by  those 
who  remain  in  a  lethargic  condition,  the  result  of  a  delusion 
(see  p.  399) ;  as  when,  for  instance,  the  patient  thinks  that 
he  has  received  a  command  from  a  higher  power  to  remain 
in  such  a  condition. 

The  intellectual  functions,  memory,  reasoning,  attention,  etc., 
may  be  increased  or  lessened  in  power. 

Increased  intellectual  function  is  rare,  usually  occurring  in 
the  early  stages  of  mania. 

Diminished  intellectual  function  occurs  in  various  functional 
and  organic  brain-diseases  (neurasthenia,  brain  tumor,  etc.) ; 
and,  when  marked,  is  known  as  dementia. 

The  function  usually  first  impaired  is  memory. 

It  must  be  remembered  that  memory  for  recent  events  may 
be  impaired,  when  that  for  those  long  passed  is  preserved. 

Loss  of  the  poiver  of  fixing  the  attention  usually  occurs  next 
in  order.  In  this  there  is  inability  to  concentrate  the  atten- 
tion upon  one  subject  for  any  length  of  time.  The  mind 
naturally  wanders  from  one  subject  to  another  ;  but  the  nor- 
mal individual  can,  by  the  exercise  of  the  will,  more  or  less 
completely  exclude  subjects  foreign  to  that  under  considera- 
tion. In  the  individual  suffering  from  failure  of  the  mental 
powers,  this  power  of  the  will  is  much  diminished  or  lost. 

Incoherence  may  be  due  either  to  loss  of  this  faculty  or  to 
heightened  cerebral  activity. 

In  the  former  it  is  due  to  inability  to  complete  the  mental 
act,  the  mind  wandering  to  another  subject  before  the  pre- 
vious train  of  thought  is  completed. 

When  occurring  in  the  latter  condition,  it  is  due  to  the 
excessive  rapidity  of  the  mental  acts,  thoughts  rushing  in  to 


INSANITY.  399 

the  brain  so  fast  that  there  is  inability  to  translate  them  fully 
into  words.     This  form  is  seen  in  maniacal  states. 

Hallucinations,  illusions,  and  delusions  are  frequent  symp- 
toms of  insanity. 

A  hallucination  may  be  defined  as  a  sensation  perceived  by 
the  mind,  through  any  of  the  senses,  without  any  external 
cause  capable  of  producing  it.  In  the  order  of  frequency  of 
their  implication,  the  senses  affected  are  sight,  hearing,  touch, 
smell,  taste. 

Illusions  are  closely  related  to  hallucinations.  They  are 
due  to  an  erroneous  conception  by  the  mind  of  an  external 
object  perceived  by  any  of  the  senses,  or,  in  other  words,  the 
perception  of  an  object  in  characters  which  it  does  not  possess. 

Hallucinations  and  illusions  may  be  due  to  other  causes 
than  mental  unsoundness.  They  are  only  evidences  of  in- 
sanity when  the  patient  believes  that  they  are  realities  in 
spite  of  evidence  to  the  contrary  which  may  be  obtained  by 
the  exercise  of  his  other  senses. 

An  insane  delusion  may  be  defined  to  be  "  a  faulty  belief 
concerning  a  subject  capable  of  physical  demonstration,  out 
of  which  the  person  cannot  be  reasoned  by  adequate  methods 
for  the  time  being "  (H.  C.  Wood).  In  other  words,  the 
essential  feature  of  an  insane  hallucination  or  delusion  is  loss 
of  the  power  to  receive  and  weigh  evidence. 

The  delusion  may  have  for  its  basis  a  hallucination,  may 
be  due  to  some  disordered  bodily  sensation,  some  trivial  cir- 
cumstance may  give  rise  to  it,  or  it  may  be  self-engendered 
in  the  mind.  For  instance,  the  hearing  of  voices  may  give 
rise  to  the  delusion  of  persecution,  a  real  and  persistent  ab- 
dominal pain  to  the  delusion  of  pregnancy,  or  the  seeing  of 
two  persons  conversing  together  that  they  are  conspiring 
against  the  patient. 

Delusions  may  be  classified  into  expansive  delusions,  hypo- 
chondriacal delusions,  delusions  of  persecution. 

Expansive  delusions  usually  relate  either  to  the  mental  or 
physical  qualities,  wealth,  or  business  prospects  of  the  person 
who  has  them.  Thus  he  is  the  strongest  man  in  the  world, 
has  millions  of  money,  is  a  great  genius,  etc.  They  are 
sometimes  termed  delusions  of  grandeur. 

Hypochondriacal  delusions  relate  to  imaginary  disease  from 


400  MENTAL  DISEASES. 

which  the  patient  thinks  he  suffers.  Thus  he  thinks  he  has 
an  incurable  disease,  or  that,  if  he  moves,  his  bones  will 
break,  etc.  These  delusions  often  are  based  upon  some  real 
but  slight  ailment.  As  has  already  been  said,  neurasthenics 
(see  p.  343)  often  exaggerate  their  symptoms  and  become 
hypochondriacal.  Such  patients,  however,  may  be  able  to 
perform  the  usual  duties  of  life,  and  hence  should  not  be 
termed  insane.  But  when  these  beliefs  either  dominate  the 
actions  of  the  patient  or  exist  entirely  in  the  imagination, 
they  become  evidences  of  insanity. 

Delusions  of  persecution  are  usually  associated  with  hallu- 
cinations. The  patient  believes  himself  to  be  the  victim  of 
persecution  either  by  some  unknown  persons  or  agents ;  or  he 
may  tix  upon  some  certain  person  as  the  cause  of  his  troubles, 
in  which   event  he   becomes   a   lunatic   of   most   dangerous 

Delusions  must  also  be  divided  into  systematized  and  non- 
systematized  delusions  :  The  former  is  one  concerniug  which 
the  patient  reasons,  and  the  reality  of  which  he  defends  more 
or  less  logically.  Thus,  if  a  man  asserts  that  a  certain  person 
is  trying  to  jjoison  him  by  means  of  noxious  gases,  and  that 
it  is  being  done  because  the  patient  had  discovered  a  great 
secret  concerning  this  person,  he  would  have  a  systematized 
delusion. 

But  if  the  patient  merely  asserted  that  he  was  being  poi- 
soned without  attempting  to  give  reasons  why  it  was  so,  it 
would  be  an  unsystematized  delusion. 

Imperative  conceptions  :  Certain  ideas  may  arise  in  the  mind 
of  a  patient  which  to  more  or  less  degree  dominate  his  actions, 
but  the  falsity  of  which  is  recognized.  Such  ideas  are  known 
as  imperative  conceptions.  The  various  morbid  fears  spoken 
of  among  the  symptoms  of  neurasthenia  are  examples. 

Related  to  these  are  morbid  impulses,  in  which  the  patient 
has  an  irresistible  desire  to  do  certain  acts.  Thus,  to  steal 
(kleptomania),  to  set  fire  to  buildings  (pyromania),  etc. 

Or  the  impulse  may  consist  of  the  performance  of  some 
action,  as  touching  certain  objects,  rubbing  the  arms  against 
the  sides  of  the  body,  etc. 

These  impulses,  in  most  instances,  are  symptoms  of  some 
form  of  insanity  ;  but  they  may  be  due  to  neurasthenia,  in 


INSANITY.  401 

which  case  their  existence  is  recognized  and  the  patient  fights 
against  them. 

Morbid  desires  are  perversions  of  natural  appetites.  For 
instance,  the  various  forms  of  sexual  perversion  or  the  eating 
of  filth,  etc. 

Abnormal  development  of  the  sexual  passion  is  termed 
sdtyriasis  in  the  male  and  nymphomania  in  the  female. 

Erotomania  is  a  term  applied  to  a  condition  in  which  a 
person  conceives  a  strong  attachment  to  one  of  the  opposite 
sex,  perhaps  whom  he  has  never  seen,  but  in  Avhich  there  is 
no  real  sexual  excitement. 

Delirium  :  When  we  have  a  perversion  of  mental  processes, 
consisting  of  incoherent  speech,  hallucinations,  illusions,  delu- 
sions, inability  to  fix  the  attention,  restlessness,  etc.,  which  is 
due  to  organic  brain  disease,  toxsemise  in  infectious  fevers, 
mineral  poisons,  alcohol,  or  inanition,  while  in  reality  the 
patient  is  "  insane,"  we  do  not  speak  of  it  as  such,  but  term 
the  condition  delirium. 

Insanity — Classification. 

A  satisfactory  classification  of  mental  diseases  is  difficult,  if 
not  impossible,  to  make.  There  have  been  nearly  as  many 
classifications  as  there  have  been  writers  upon  the  subject. 
That  of  H.  C.  Wood  is  as  follows  : 

Group  L  Complicating  insanities :  Those  which  are  the 
outcome  of  distinct  organic  disease  of  the  brain,  not  dependent 
upon  acquired  or  inherited  constitutional  diathesis.  In  this 
class  would  be  grouped  the  mental  disturbances  accompanying 
meningitis,  encephalitis,  brain  tumor,  apoplexy,  paretic  de- 
mentia, and  senile  dementia. 

Group  II.  Constitutional  insanities,  in  which  the  cerebral 
disorder  is  due  to  an  acquired  or  inherited  constitutional  dis- 
ease, including  diatheses,  constitutional  diseases,  and  subacute 
and  chronic  poisonings,  involving  widespread  areas  of  the 
body.  Gouty,  epileptic,  hysterical,  syphilitic,  lead,  and  alco- 
holic insanities  would  be  included  in  this  class. 

Group  III.  Pure  insanities,  in  which  the  mental  disorder 
is  not  dependent  either  upon  demonstrable  organic  brain  dis- 
ease or  upon  a  diathetic  or  other  poison.  This  group  is  divided 
26— N.  D. 


402  MENTAL  DISEASES. 

into  two  subgroups,  which  may  be  termed  functional  insani- 
ties and  the  neuropathic  insanities. 

Functional  insanities,  or  those  which  are  liable  to  occur  in 
almost  any  person  who  may  recover  and  during  later  life 
remain  free  from  mental  aberration,  include  melancholia, 
mania,  confusional  insanity,  and  terminal  dementia. 

Newopathic  insanities,  or  those  which  are  the  outgrowth 
of  an  original  vice  of  nervous  construction,  such  vice  of  con- 
struction not  being  sufficient  to  reveal  itself  by  anatomical 
peculiarities,  but  showing  its  presence  throughout  life  in 
functional  aberration,  inchide  constitutional  affective  insanity 
(folic  raisonante),  moral  insanity,  paranoia,  and  periodic  in- 
sanity (circular  insanity). 

For  the  purposes  of  the  student,  the  simplest  division  is 
aceording  to  the  symptoms  produced ;  hence  into  melancholia, 
mania,  paranoia,  dementia,  and  paralytic  dementia,  since  all 
cases  of  insanity  from  whatever  cause  partake  of  the  charac- 
teristics of  one  or  the  other  of  these  forms.  This  classifica- 
tion will,  in  the  main,  be  here  adopted. 

Periodic  or  recurrent  insanity,  while  belonging  to  both, 
mania  and  melancholia,  merits  separate  consideration,  as  do 
also  some  cases  due  to  certain  special  causes,  and  which  pos- 
sess some  special  distinguishing  features. 

MELANCHOLIA. 

Definition  :  Melancholia  is  a  disorder  of  the  mind  and  body, 
due  to  an  excitement  of  the  depressive  emotions.  These  emo- 
tions are  often  temporarily  excited  by  various  causes,  but 
when  excited  without  cause  or  to  a  greater  extent  and  for  a 
longer  period  than  is  justified  by  the  cause,  melancholia  may 
be  said  to  exist.  Melancholia  may  hence  be  defined  as  "  a 
disorder  characterized  by  a  feeling  of  misery  which  is  in  ex- 
cess of  what  is  justified  by  the  circumstances  in  M'hich  the 
individual  is  placed."  ^ 

The  most  active  factor  in  the  etiology  is  the  inheritance 
of  a  nervous  system  that  is  feeble,  unstable,  and  possesses  de- 
ficient powers  of  recuperation.     In  such,  any  unusual  strain 

*  Tuke's  Dictionary  of  Psychological  Medicine. 


MELANCHOLIA.  403 

upon  the  mind  or  body  may  cause  an  attack.  Hence,  in 
such,  puberty,  the  climacteric,  pregnancy,  prolonged  physical 
or  mental  exertion,  misfortune,  prolonged  anxiety,  acute  and 
chronic  diseases  may  act  as  exciting  causes.  Often,  with  the 
exception  of  a  neuropathic  ancestry  and  the  possession  of  a 
nervous  system,  such  as  above  described,  no  cause  can  be 
ascertained. 

Symptoms. 

Simple  melancholia,  or  that  in  which  there  is  a  prolonged 
period  of  mental  depression  without  delusions,  will  be  first 
considered. 

The  symptoms  come  on  gradually ;  at  first  insomnia  and 
pain  or  sense  of  pressure  at  the  vertex  or  occiput,  loss  of 
appetite,  constipation,  failure  of  digestion,  irritability,  and 
some  depression  of  spirits  will  be  complained  of.  As  the 
condition  progresses  the  symptoms  continue,  while  the  patient 
becomes  more  and  more  depressed.  He  loses  all  interest  in 
his  business  and  family  ;  has  forebodings  of  all  sorts  of  future 
trouble ;  and  dwells  upon  his  past  errors  of  life  and  deficiencies. 
When  aroused,  a  coherent  conversation  can  be  maintained  and 
a  clear  account  of  the  symptoms  given.  He  frequently  ex- 
presses a  desire  to  die.  Food  is  either  refused  or  only 
sparingly  taken  by  him  when  forced.  The  expression  of  the 
face  is  that  of  abject  misery,  and  the  eye  is  expressionless.  The 
temperature  is  normal  or  snbnormal.  The  tongue  is  flabby 
and  frequently  coated  ;  the  bowels  constipated;  and  the  urine 
scanty,  high-colored,  and  often  full  of  urates.  Aneemia  is 
often  present,  and  in  women  menstruation  is  scanty  or  absent. 
Some  loss  of  weight  may  occur. 

Melancholia  with  delusions  and  agitation  (melancholia  agi- 
tata) :  If  the  symptoms  described  above  do  not  ameliorate, 
they  usually  become  more  aggravated.  Hallucinations  and  de- 
lusions appear;  for  instance,  voices  are  heard  reproaching  him 
for  the  commission  of  all. sorts  of  crimes;  he  states  that  he  is 
doomed  to  eternal  punishment,  or  that  dire  misfortune  will 
overtake  himself  and  family,  or  already  has  done  so.  Insom- 
nia and  refusal  of  food  become  more  marked ;  the  patient  is 
restless,  may  walk  continually  to  and  fro  wringing  the  hands, 
and  wee])ing  and  wailing.     Suicidal  impulses  are  marked,  and 


404  MENTAL  DISEASES. 

also  ill  some  cases  are  homicidal  ones.  Such  patients  often 
injure  their  persons  by  picking  at  parts  of  the  body  until  the 
skin  is  worn  away,  pulling  hair  from  the  head,  or,  in  extreme 
cases,  may  actually  mutilate  themselves.  The  extremities  are 
cold,  possibly  congested,  and  all  the  bodily  functions  are  iu 
abeyance. 

Melancholia  with  delusions  and  stupor  (melancholia  atto- 
nita) :  Some  cases,  instead  of  passing  from  the  simple  into  the 
agitated  form,  pass  into  a  stuporous  condition,  or  stupor  may 
follow  agitation.  This  may  occur  comparatively  suddenly, 
and  is  due  to  the  domination  of  delusions  and  to  more  or  less 
suspension  of  the  will-power.  Delusions  such  as  "  they  would 
go  to  pieces  if  moved,"  "  that  the  world  had  come  to  an  end," 
are  types.  During  the  height  of  the  disease  it  is  impossible  to 
ascertain  the  nature  of  the  delusions.  The  patient  refuses  to 
talk,  and  sits  absolutely  quiet  with  the  head  down.  The  ex- 
pression is  either  anxious  or  terrified,  and  the  eyes  fixed. 
If  made  to  stand,  that  position  is  maintained  until  he  is  made 
to  change  it.  When  an  attempt  is  made  to  cause  him  to  change 
the  position,  it  causes  irritation  and  may  be  resisted.  Rigidity 
of  the  muscles  is  common.  Some  cases  are  cataleptic.  Food 
is  either  not  taken  at  all  or  only  when  placed  in  the  mouth, 
when  it  may  be  swallowed.  Urine  and  faeces  when  passed  are 
done  so  involuntarily.  The  temperature  is  subnormal,  and  the 
extremities  cold  and  cyanotic.    There  is  marked  loss  of  weight. 

Melancholia — diagnosis  :  It  must  be  remembered  that  men- 
tal depression  is  a  frequent  premonitory  symptom  of  other 
forms  of  insanity ;  but,  of  course,  when  such  is  the  case,  it 
persists  but  a  short  time  before  other  symptoms  develop. 

Simple  melancholia  in  its  early  stages  may  be  confounded 
with  neurasthenia — in  fact,  neurasthenia  always  precedes  the 
development  of  the  melancholia.  When  the  depression  be- 
comes so  great  as  to  dominate  the  life  of  the  patient,  the  latter 
may  be  said  to  supervene. 

Hypochondria  also  resembles  melancholia,  and  may  lead  to 
it.  The  hypochondriac  is  constantly  looking  for  symptoms 
of  disease,  and  exaerfferates  anv  abnormal  sensation  which  he 
may  have;  but  so  long  as  he  is  not  affected  in  his  relation  to 
his  business  and  family  affairs,  and  has  no  actual  delusions. 


MELANCHOLIA.  405 

he  cannot  be  said  to  be  insane.  Hypochondriacal  dchisions,  on 
the  other  hand,  are  often  present  in  eases  of  melancliolia. 

Cases  of  general  ])aresis  in  which  there  is  depression  may 
be  mistaken  for  melancholia.  The  tinding  of  the  physical 
symptoms  of  the  former  disease  (p.  420)  will  enable  the  dis- 
tinction to  be  made. 

Paranoia,  with  depressive  and  persecutory  hallucinations 
and  delusions,  is  distinguished  by  the  facts  that  the  delusions 
are  systematized  and  that  the  patient  thinks  he  is  persecuted 
wrongfully ;  while  the  victim  of  melancholia  believes  that  he 
deserves  his  sufferings.  Melancholia  with  stupor  may  be 
confounded  with  primary  dementia  (p.  416).  The  fact  that 
melancholia  is  one  of  the  stages  of  circular  insanity  rnust 
be  remembered. 

Melancholia — prognosis :  This  is  fairly  good,  about  60  per 
cent,  of  the  cases  recovering.  It  is  best  in  tlie  simple,  worst 
in  the  stuporous  form.  The  average  duration  is  from  nine  to 
twelve  months ;  but  recovery  may  occur  sooner  or  later.  It 
has  occurred  after  the  condition  has  persisted  for  years.  Cases 
which  do  not  recover  die  from  exhaustion  or  end  in  terminal 
dementia  (see  p.  414). 

Melancholia — treatment :  The  first  question  that  often  arises 
is,  Should  the  patient  be  treated  at  home  or  in  a  hospital? 
If  the  case  is  simple  and  the  patient  possesses  means  to  enable 
him  to  carry  out  the  measures  essential,  he  may  be  treated  at 
home.  In  severe  cases  with  delusions,  or  where  the  financial 
resources  are  not  ample,  a  hospital  devoted  to  the  treatment 
of  mental  diseases  is  the  most  suitable  place.  In  the  mildest 
cases  the  possibility  of  suicide  must  always  be  borne  in  mind 
and  the  patient  closely  watched. 

A  complete  or  partial  rest  cure  is  the  preferable  plan  of 
treatment  for  mild  cases.  Rest  in  bed,  say  from  6  p.  m.  until 
noon  of  the  next  day,  with  an  outdoor  life  for  the  remainder 
of  the  day,  the  ingestion  of  plenty  of  nutritious  and  digestible 
food,  is  an  excellent  plan.  Massage  and  electricity  (general 
faradization)  should  be  employed  when  active  exercise  is  not 
taken. 

As  some  cases  of  melancholia  appear  to  be  due  to  an  auto- 
intoxication, the  bowels  should  be  kept  open  by  appropriate 
measures.     In  cases  su^^pected  of  being  so  caused,  intestinal 


406  MENTAL  DISEASES. 

antiseptics  (salol  or  beta-naphthol)  may  be  given.  Tonics 
of  various  kinds — strychnine,  arsenic,  mineral  acids,  and  the 
glycero-phosphates  of  sodium  or  calcium — should  be  given. 

For  sleeplessness,  the  warm  bath  or  pack  may  be  tried. 
When  this  fails,  trional  (gr.  x-xx  in  hot  milk  or  soup)  is 
usually  efficacious.  When  there  is  much  agitation,  opium 
given  three  times  daily,  beginning  with  a  moderate  dose  and 
increasing  if  required,  is  often  of  service.  Hydrobroraate  of 
hyoscine  is  also  valuable. 

If  food  is  refused,  the  patient  must  be  fed  by  introducing 
several  times  daily  a  soft-rubber  catheter  through  the  nose 
into  the  oesophagus,  and  milk,  eggs,  and  other  concentrated 
food  given  through  it.  As  .soon  as  possible,  mild  outdoor 
exercise  (bicycling,  golf,  riding,  etc.)  should  be  encouraged. 
A  sea  trip  is  of  benefit,  but  prolonged  travel  and  its  attendant 
excitement  and  fatigue  should  be  avoided. 


MANIA. 

Definition :  Mania  is  a  form  of  insanity  characterized  in  its 
full  development  by  mental  exaltation  and  bodily  excitement.^ 

Etiology :  As  in  melancholia,  the  patient  will  usually  have 
a  neurotic  temperament  or  heredity.  When  such  individuals 
are  subjected  to  physical  or  mental  overwork,  prolonged 
worry,  shocks  of  any  sort,  syphilis,  exhaustion  attending  the 
puerperal  condition,  alcoholic  and  sexual  excesses,  mania  may 
result.  Transitory  maniacal  symptoms  may  occur  in  paretic 
dementia,  epileptic  insanity,  or  may  be  due  to  toxaemias, 
as  lead,  etc. 

Symptoms. 

Mania  may  be  developed  suddenly ;  but  there  is  usually  a 
prodromal  period  lasting  from  a  few  days  to  several  months. 
These  symptoms  consist  of  depression  of  spirits,  lassitude, 
lack  of  the  power  of  fixing  the  attention,  disinclination  to 
work,  loss  of  appetite,  insomnia,  constipation,  etc. — in  fact, 
the  symptoms  of  a  simple  melancholia.  The  maniacal  symp- 
toms when  they  develop  may  be  of  various  grades  of  severity 

^  Tuke's  Dictionary  of  Psychological  Medicine. 


MANIA.  407 

and  duration,  hence  we  have  subacute,  acute,  hyperacute,  and 
chronic  mania. 

Subacute  or  hypomania :  After  the  period  of  depression 
mentioned  above  the  patient  is  noticed  to  be  abnormally 
happy  and  gay.  There  is  increased  activity  of  all  the  physio- 
logical operations  of  the  intellect.  Various  projects — busi- 
ness, political,  social,  etc. — are  devised,  and  as  soon  abandoned. 
The  patient  is  loquacious,  and  his  conversation  may  be  witty 
and  even  brilliant.  The  memory  is  also  more  active  than 
normal ;  and  such  patients  are  often  able  to  remember  events, 
to  memorize  poetry,  etc.,  that  in  their  normal  condition  would 
be  impossible.  A  marked  tendency  to  dissipation  of  all  sorts 
often  develops.  There  are  also  increased  egotism  and  pugna- 
ciousness ;  they  may  be  said  to  go  about  with  a  "chip  on  their 
shoulders."  Physically  there  are  increased  activity  and  restless- 
ness ;  they  always  want  to  be  on  the  gO;  and  seem  incapable 
of  experiencing  fatigue.  There  are  no  delusions,  and  their 
actions  and  thoughts  are  coherent.  In  fact,  in  some  (;ases  it 
is  only  by  noting  the  change  from  a  previous  normal  condi- 
tion that  the  insanity  of  the  patient  is  determined.  This  con- 
dition may  be  recovered  from ;  or,  after  a  greater  or  less 
period,  passes  into  the  stage  of 

Acute  mania :  In  this,  the  emotional  excitement  increases. 
Constantly  shifting  hallucinations,  illusions,  and  sometimes 
delusions  are  present.  The  patient  is  noisy,  and  pours  out 
continually  a  stream  of  incoherent  threatenings,  obscenities, 
prayers,  and  blasphemies.  Ideas  seem  to  crowd  into  the 
brain  with  such  rapidity  that  he  has  not  time  to  express 
them  all ;  hence  begins  something  new  before  he  has  fin- 
ished the  old,  and  any  slight  incident  at  once  suggests  new 
combinations  of  words  and  acts.  Insomnia  is  marked.  There 
is  usually  great  sexual  excitement.  The  patient  is  practically 
never  quiet,  rushing  and  jumping  about  his  apartment,  mak- 
ing grimaces  and  gestures  ;  destroys  his  clothing  and  what- 
ever else  he  can  lay  his  hands  upon.  The  appetite  is  vora- 
cious, l>ut  there  is  great  loss  of  weight.  The  temperature  is 
normal  or  very  slightly  increased.  In  very  severe  cases  filth 
of  all  sorts  is  smeared  upon  the  person,  about  the  apartment, 
and  even  eaten.  Alternating  with  these  periods  of  excite- 
ment there  may  be  brief  periods  of  calm. 


408  MENTAL  DISEASES. 

The  symptoms  in  all  cases  of  acute  mania  are  not  so  violent 
as  described  above,  but  between  it  and  the  subacute  form 
various  degrees  of  severity  occur. 

Hyperacute  or  acute  delirious  mania :  This  form  is  also 
known  as  acute  delirium,  typhomania,  delirium  grave,  and 
Bell's  disease.  This  form  is  rare,  and  usually  develops  more 
suddenly  than  does  acute  mania,  as  after  a  very  brief  pro- 
dromal period  delirium  appears.  From  the  onset  this  is  vio- 
lent. The  attention  cannot  be  aroused  ;  there  seems  to  be  in- 
difference to  all  surroundings.  The  delusions  and  hallucina- 
tions are  of  a  character  that  excite  fear  and  apprehension 
in  the  patient.  Insomnia  is  profound,  and  there  is  great 
motor  restlessness.  Food  is  often  refused.  The  pulse  is 
rapid.  The  temperature  ranges  from  100°  to  104°  F.  or  more, 
and  the  tongue  is  dry  and  coated. 

During  the  course  of  the  disease  remissions  in  the  symp- 
toms may  occur,  only  to  return  with  increased  severity.  Most 
cases  in  a  few  days  sink  into  a  comatose  condition  and  die. 

Chronic  mania :  This  is  one  of  the  modes  of  termination  of 
acute  mania.  As  the  patient  passes  into  this  condition  the 
mental  and  physical  excitement  and  incoherence  gradually 
diminish  until  for  the  greater  part  of  the  time  he  is  fairly 
quiet  and  orderly.  At  intervals,  however,  there  may  be 
periods  of  acute  maniacal  excitement.  The  delusions  often 
become  more  fixed.  Such  patients  frequently  amagine  them- 
selves to  be  some  great  ]>ersonage,  and  dress  and  act  accord- 
ingly, a  condition  sometimes  termed  secondary  paranoia  (see 
Paranoia).  Homicidal  impulses  are  sometimes  present.  Along 
with  these  symptoms  there  is  gradual  failure  of  mental  power 
or  dementia,  although  it  may  be  several  years  before  this 
occurs.  Under  proper  supervision,  such  patients  may  often 
be  made  to  do  simple  work. 

Mania — diagnosis :  In  subacute  and  acute  mania  the  history 
will  generally  make  the  diagnosis  plain. 

Hyperacute  mania  may  be  confounded  with  acute  menin- 
gitis and  the  delirium  of  typhoid  fever  and  pneumonia.  From 
the  former  it  is  distinguished  by  the  absence  of  headache, 
muscular  rigidity,  and  motor  paralysis.  The  history  of  the 
mode   of  onset,  absence  of  spots,  enlarged   spleen,  and   the 


MANIA.  409 

Widal  reaction  will  be  sufficient  to  distinguish  it  fioni 
typhoid  fever  ;  while  a  physical  examination  of  the  lungs 
will  disclose  the  existence  of  pneumonia. 

Chronic  mania  might  be  confounded  with  primary  paranoia 
(p.  410),  but  the  pi-evious  history  (an  attack  of  acute  mania) 
and  the  failure  of  mental  power  make  the  diagnosis  plain. 

Mania — prognosis :  Cases  of  subacute  mania  usually  re- 
cover, but  are  apt  to  have  relapses.  The  average  duration  of 
acute  mania  is  from  three  to  six  months,  but  may  last  longer. 
It  may  terminate  either  by  recovery  (70  per  cent.) ;  in  chronic 
mania,  dementia,  or  death  from  exhaustion. 

Improvement  in  the  physical  condition  without  coincident 
improvement  in  the  mental  is  a  bad  prognostic  sign,  and  indi- 
cates passage  into  the  chronic  or  demented  state. 

Patients  with  hyperacute  mania  usually  die. 

Cases  of  chronic  mania  sometimes  recover  even  after  the 
lapse  of  several  years  ;  but,  as  a  rule,  they  do  not. 

Mania — treatment :  Unless  a  patient  has  large  means  and  can 
command  the  requisite  attendance,  removal  to  a  hospital  for 
the  insane  is  the  proper  course  to  pursue.  If  treated  at  home, 
he  should  be  constantly  watclied  day  and  night ;  all  furniture, 
excepting  a  mattress,  which  should  be  protected  by  a  covering 
of  canvas,  removed  from  the  room ;  and  the  ])atient  dressed 
in  a  combination  suit  of  similar  material  laced  up  the  back. 
Mechanical  appliances  for  restraint  are  rarely  necessary,  and 
are  harmful. 

Plenty  of  nutritious  and  easily  digested  food  is  essential. 
If  refused  by  the  patieyt,  it  should  be  administered  as  advised 
in  cases  of  melancholia. 

For  the  insomnia,  prolonged  warm  baths  or  hot  packs  are 
often  useful.  If  these  fail,  hyoscine  hypodermically,  trional, 
or  paraldehyde  may  be  tried.  The  bowels  and  kidneys  must 
be  kept  active,  and  ferruginous  and  other  tonics  may  be 
given.  If  great  exhaustion  is  present,  alcoholic  stimulants 
are  indicated.  The  treatment  of  these  cases  by  absolute  rest 
in  bed  has  been  very  successful.  If  there  is  suspicion  of  pre- 
vious syphilitic  infection,  specific  treatment  should  be  em- 
ployed. 


410  MENTAL  DISEASES. 

PERIODIC  OR  RECURRENT  INSANITY. 

Definition :  This  term  is  applied  to  attacks  of  either  melan- 
cholia or  mania,  or  of  both,  which  recur  at  varying  intervals 
of  time,  the  patient  being  in  a  state  of  mental  health  between 
the  attacks.  Thus  S.  Weir  Mitchell  has  reported  the  case 
of  a  woman  who  each  March,  for  sixteen  years,  has  had  an 
attack  of  melancholia  lasting  until  the  following  Septem- 
ber. The  author  has  had  under  observation  a  girl  who,  for 
the  past  seven  years,  each  December  becomes  maniacal,  and 
remains  so  for  from  four  to  five  months.  This  periodicity  is 
not  always  a  feature,  the  sane  intervals  differing  in  duration 
in  the  same  patient.  In  some  patients  there  is  a  regular  cycle 
of  mania,  melancholia,  or  vice  versa,  and  a  sane  period.  This 
is  known  as  circular  insanity. 

Etiology :  Most  of  these  patients  have  a  neurotic  heredity. 
There  is  often  a  history  of  insanity,  epilepsy,  or  similar  dis- 
ease in  the  fiiraily ;  and  even  in  their  normal  condition  they 
show  various  peculiarities  and  eccentricities.  Puberty,  the 
climacteric,  or  shock  may  act  as  exciting  causes. 

Recurrent  insanity — symptoms :  These  usually  appear  sud- 
denly, prodromes,  if  they  occur  at  all,  being  of  very  brief 
duration.  Otherwise  the  symptoms  are  those  of  the  various 
forms  of  melancholia  or  mania,  as  the  case  may  be. 

In  some  of  these  cases  there  are  pronounced  imperative 
conceptions  and  morbid  impulses,  leading  the  patient  to  steal, 
commit  crimes,  commit  great  sexual  excesses,  or  indulge  in  a 
prolonged  alcoholic  debauch.  Along  with  the  mental  symp- 
toms are  cardiac  palpitation,  cold  extremities,  insomnia,  loss 
of  appetite,  etc. 

The  treatment  of  the  attack  is  that  of  the  form  of  insanity 
present.  Nothing  seems  to  have  any  influence  in  preventing 
a  recurrence ;  but  a  quiet,  regular  mode  of  living  should  be 
enjoined. 

PARANOIA  OR  MONOMANIA. 

Synonyms — definition :  This  form  of  insanity,  also  some- 
times termed  progressive  systematized  insanity,  has  been  de- 
fined to  be  one  dependent  upon  original  neurotic  vices, 
accompanied  by  more  or  less  distinctly  systematized  delu- 
sions, persistent,  and  without  cyclical  delusions  (H.  C  Wood). 


PARANOIA   OR  MONOMANIA.  411 

The  delusions  may  be  of  an  ambitious  nature,  a  form 
known  as  megalomania ;  or,  what  is  more  commonly  the  case, 
of  a  depressive  nature,  constituting  the  delusion  (jf  persecu- 
tion. In  some  cases  both  forms  may  be  combined.  Such 
patients  are  often  able  to  carry  on  business  and  other  affairs 
of  life  without  suspicion  being  directed  to  their  condition ; 
but  close  investigation  will  show  that  while  such  may  be  the 
case,  they  are,  to  a  more  or  less  extent,  dominated  by  their 
delusions. 

Etiology :  As  has  been  denoted  by  the  definition,  the  great 
majority  of  these  cases  depend  upon  a  hereditary  neuropathy, 
or  neuro-degenerative  taint.  In  some  instances  either  pro- 
longed worry,  mental  shock,  or  dissipation  appears  to  act  as 
an  exciting  cause.  Some  cases  appear  to  be  due  to  functional 
perversions  of  the  cerebral  faculties  occurring  in  the  course 
of  dreams. 

Symptoms :  In  a  large  number  of  paranoiacs  peculiarities 
have  been  noted  before  the  actual  outbreak  of  the  disorder. 
Mentally,  these  consist  of  excessive  egotism,  irritability,  sus- 
piciousness, eccentricities  in  dress  or  manners,  excessive 
timidity,  imjierative  conceptions  and  impulses,  agarophobia, 
mysophobia,  or  other  similar  peculiarities  (see  Neurasthenia 
and  Tic  Convulsif ). 

Physically,  some  of  the  stigmata  of  degeneration  are  usually 
present,  and  a  previous  tendency  to  chorea,  convulsions,  and 
similar  conditions  will  often  have  been  present.  Hallucina- 
tions, especially  of  hearing,  frequently  precede  the  develop- 
ment of  delusions,  which  are  then  usually  based  upon  them. 
The  symptoms  may  become  fully  developed  either  early  or 
late  in  life.  Some  cases  never  advance  beyond  the  develop- 
ment of  some  of  the  peculiarities  above  mentioned.  Usually 
the  subject  has  a  feeling  that  his  merits  are  not  appreciated 
as  they  deserve,  begins  to  entertain  suspicions  that  some  per- 
son or  persons  are  responsible  for  this  state  of  affairs,  and  that 
some  peculiar  means,  as  the  use  of  hypnotism,  electricity,  or 
poison  in  his  food,  is  being  used  to  destroy  him.  Then  he 
finally  settles  upon  the  supposedly  guilty  person,  who  is  often 
an  agent  of  the  government  or  in  other  high  station. 

With  these  symptoms  hallucinations  are  usually  present ; 
he  hears  the  voices  of  persons  reviling  or  threatening  him  ;  he 


412  MENTAL  DISEASES. 

tastes  the  poison  in  his  food  or  feels  the  poisonous  gases  blow- 
ing over  him.  A  conversation  between  two  people  on  the 
street,  a  peculiar  gesture,  or  other  commonplace  occurrences 
or  remarks  are  regarded  as  directed  against  him  and  advanced 
as  proofs  of  the  correctness  of  his  views. 

Other  patients  think  that  they  have  made  or  are  on  the 
verge  of  making  great  discoveries;  that  they  are  great  poets 
or  have  improved  methods  of  government,  which  they  are 
continually  advancing  (megalomania) ;  or  that  they  are  beloved 
by  some  personage  of  higher  station  in  life  ;  or  it  may  be  that 
they  love  this  person,  whom  they  pursue  with  their  attentions 
(erotomania).  Then  often,  when  they  find  that  their  supposed 
merits  are  not  appreciated,  a  cause  is  looked  for,  and  the  de- 
lusion of  persecution  develo])s.  At  times  they  invoke  the 
law  to  protect  them,  and,  finding  that  it  does  not  do  so,  it 
is  taken  into  their  own  hands,  and  thus  crimes  are  com- 
mitted. 

Another  type  is  the  religioua  'paranoiac,  Avho  gives  himself 
up  to  excessive  piety  and  devotion,  and  either  sees  the  Virgin 
Mary,  Jesus  Christ,  or  some  of  the  saints,  or  hears  them  talk 
to  him.  Sexual  perversions  and  masturbation  are  common 
in  this  form. 

The  above  illustrate  the  usual  forms  in  which  this  condi- 
tion is  manifested.  Of  course,  different  cases  vary  in  the 
nature  of  their  delusions  and  in  the  eifects  which  their  delu- 
sions have  upon  them. 

At  intervals,  cerebral  excitement,  insomnia,  or  attacks  of 
mania,  melancholia,  or  acute  dementia  may  occur.  Also  they 
often  exhibit  some  of  the  many  manifestations  of  hysteria,  or 
are  given  to  alcoholism  and  kindred  vices. 

Paranoia — diagnosis :  In  those  cases  in  which  the  delusion 
is  apparent,  its  mode  of  development,  fixity,  and  systematized 
character  make  the  diagnosis  easy ;  but,  on  the  other  hand, 
cases  occur  in  which  the  delusions  are  so  conformable  to  what 
occurs  in  ordinary  life  that  their  recognition  may  be  difficult. 
Thus,  in  a  case  detailed  l)y  Wood,  a  woman  accused  her  hus- 
band of  giving  her  syphilis,  and  it  was  only  after  prolonged 
investigation  that  it  was  discovered  that  the  accusation  was 
due  to  a  delusion. 

Evidence  of  a  high  degree  of  intellectual  vigor  in  certain 


DEMENTIA.  413 

directions  is  not  against  the  existence  of  paranoia;  great 
geniuses  have  been  victims  of  it. 

The  intense  egotism  and  suspicion  whi(;h  are  present  in 
nearly  all  victims  of  paranoia  and  evidences  of  a  neuropathic 
diathesis  may  serve  as  usjful  hints  in  the  investigation  of  such 
cases. 

Prognosis :  It  is  doubtful  if  a  paranoiac  ever  recovers. 
Remissions,  however,  may  occur.  Paretic  dementia  rather 
often  develops  in  paranoiacs.  The  course  of  the  disease  is 
chronic,  and  usually  ends  after  a  long  period  in  some  mental 
enfeeblement. 

Paranoia — treatment :  The  discipline  and  regular  mode  of 
living  of  a  well-regulated  asylum  are  beneficial.  It  may  be, 
however,  difficult  to  decide  whether  a  man  who  is  capable  of 
conducting  a  large  business  or  performing  intellectual  labor 
should  be  put  there.  While  the  insanity  may  be  recognized  by 
the  alienist,  it  is  often  difficult  to  convince  a  judge  or  jury ; 
and  if  such  patients  are  committed,  it  is  more  hard  to  keep 
them  there,  as  these  are  the  cases  which  are  continually  ap- 
plying for  writs  of  habeas  corpus,  and  make  no  end  of  trouble 
for  the  hospital  authorities  and  those  who  have  committed 
them.  On  the  other  hand,  it  must  be  remembered  that  a 
paranoiac  with  persecutory  delusions  is  a  most  dangerous  per- 
son to  be  at  large. 

The  enjoining  of  a  quiet,  regular  mode  of  living,  freedom 
from  care  and  worry,  and  an  outdoor  life  will  be  of  service 
as  a  prophylactic  in  those  who  exhibit  the  premonitory  symp- 
toms mentioned. 

DEMENTIA. 

Definition  :  Dementia  is  a  term  used  to  denote  a  more  or 
less  complete  enfeeblement  of  the  mental  faculties  of  a  mind 
that  was  once  normal.  The  fact  that  the  mental  functions  in 
a  dement  were  once  normal  distinguishes  dementia  from 
idiocy  and  imbecility.  The  term  is  often  used  by  the  laity, 
and  also  sometimes  by  physicians,  to  denote  any  form  of  in- 
sanity. This  is  incorrect.  It  should  only  be  used  to  denote 
those  cases  which  come  within  the  terms  of  the  definition. 
A  person  afflicted  with  acute  mania  cannot  properly  be  said 
to  be  demented. 


414  MENTAL  DISEASES. 

Etiology — varieties :  Dementia  may  be  due  to  a  number  of 
different  causes.  To  a  more  or  less  degree,  it  may  be  due  to 
disease  of  the  brain,  as  tumor,  meningitis,  syphilis,  epilepsy, 
and  the  results  of  cerebral  apoplexy.  It  is  also  sometimes 
due  to  prolonged  toxaemia,  as  from  the  effects  of  alcohol  or 
lead. 

While  some  loss  of  mental  vigor  is  a  normal  condition  of 
old  age,  in  some  cases  this  loss  goes  beyond  the  normal  limit 
and  is  associated  with  other  peculiar  features.  Such  a  condi- 
tion is  known  as  senile  dementia. 

It  may  also  occur  as  a  primary  condition,  due  to  violent 
mental  shocks  or  exhausting  physical  conditions,  as  overwork, 
infectious  diseases,  surgical  operations,  pregnancy,  etc.  The 
milder  form  is  known  as  confusional  insanity  ;  the  severe,  as 
acute  dementia,  or  stuporous  insanity.  Loss  of  memory  and 
other  of  the  higher  mental  functions  may  occur  among  other 
symptoms  of  neurasthenia.  These  are  recovered  from  as  the 
health  of  the  patient  improves ;  but,  if  neglected,  may  ter- 
minate in  permanent  dementia. 

Dementia  also  may  be  a  sequel  to  acute  insanities,  like 
mania  and  melancholia,  or  to  chronic  psychoses,  like  circular 
insanity  and  paranoia.  It  is  then  known  as  secondary  or  ter- 
minal dementia. 

Loss  of  the  mental  faculties  constitutes  part  of  the  symp- 
toms of  paresis,  or  paralytic  dementia.  Mental  enfeeblement 
occurring  as  a  consequence  of  brain  tumor,  meningitis,  apo- 
plexy, or  epilepsy  would  be  associated  with  the  physical 
symptoms  of  these  affections,  which  have  been  described. 
Besides  dementia,  other  symptoms  of  mental  disease  may 
occur  in  epileptics,  which  will  be  described  under  the  head  of 
Epileptic  Insanity.  Dementia  due  to  syphilitic  lesions  will 
be  described  under  differential  diagnosis  between  it  and 
paresis,  which  it  much  resembles. 

Secondary  or  Terminal  Dementia. 

Symptoms:  The  condition  described  as  chronic  mania  may 
precede  the  development  of  secondary  dementia,  or  the  patient 
may  pass  into  the  demented  from  the  acute  condition.  In 
the  mild  cases  there  are  loss  of  memory,  some  lack  of  judgment, 


DEMENTIA.  415 

and  possibly  some  incoherence  associated  with  delusions  siu;h 
as  have  been  described  under  Chronic  Mania.  If  the  con- 
dition is  more  pronounced,  the  patient  has  absolute  loss  of 
memory,  judgment,  and  extreme  incoherence ;  the  habits 
are  filthy,  soiling  himself  with  urine  and  faeces,  and  some- 
times eating  the  latter.  Masturbation  is  common.  As  chil- 
dren do,  so  they  are  likely  to  swallow  anything  which  comes 
into  their  possession. 

Paper,  buttons,  string,  and  all  sorts  of  rubbish  are  collected 
and  stored  about  the  person.  They  are  emotional,  laughing 
or  crying  over  trifles.  Some  patients  are  destructive  and 
given  to  outbursts  of  excitement  and  passion ;  others  are 
quiet,  sitting  in  one  place  all  day,  having  to  be  fed  and  tended 
as  a  little  child.  They  are  apt  to  become  fat.  The  expres- 
sion is  vacant,  either  a  silly  smile  or  an  angry  frown  being 
usually  present.  Such  patients,  of  course,  never  recover,  but 
they  may  live  for  years. 

Senile  Dementia. 

Etiology :  The  condition  rarely  appears  previous  to  the 
sixtieth  year.  Degeneration  of  the  bloodvessels  incident  to 
this  period  of  life,  inducing  malnutrition  of  the  brain  areas  of 
softening  and  degeneration,  is  an  active  etiological  factor. 

Symptoms  of  subacute  mania  may  precede  the  development 
of  the  dementia  ;  but  usually  the  first  symptom  noticed  is  loss 
of  memory.  At  first,  recent  events  only  are  forgotten,  while 
those  which  happened  in  the  past  are  recollected.  But  as  the 
disease  progresses  the  loss  becomes  absolute.  The  patient 
forgets  the  names  of  his  friends,  where  he  lives,  makes  a 
statement  in  the  course  of  conversation  and  in  a  moment  or 
two  repeats  it.  Such  patients  are  usually  irritable,  and  there 
is  a  tendency  to  restlessness,  especially  at  night.  They  wander 
about  the  house,  or,  may  be,  away  from  it  and  lose  their  way. 
As  the  disorder  progresses,  the  patient  becomes  unclean  and 
negligent  about  his  person  ;  erotic  tendencies  also  often  be- 
come prominent ;  he  falls  in  love  with  young  women  ;  may 
expose  himself  in  public  or  attempt  liberties  with  children  ; 
niasturl)ation  is  also  common.  Owing  to  his  lack  of  will  and 
judgment,  he  may  squander  his  property  or  make  a  foolish 


416  MENTAL  DISEASES. 

will.  Hallucinations  sometimes  develop,  as  do  also  delusions, 
usually  of  a  persecutoiy  or  hypoeli(jndriacal  character. 

Prognosis :  The  course  of  this  disorder  is  steadily  onward, 
death  usually  occurring  in  from  three  to  five  years. 

Senile  dementia — treatment :  The  treatment  is  hygienic  and 
symptomatic.  The  erotic  propensities  and  lack  of  will-power 
existing  in  these  patients  must  be  borne  in  mind,  and,  if  they 
are  not  placed  in  a  hospital,  they  should  be  closely  watched. 
When  wealthy,  they  are  often  the  victims  of  designing  women, 
who  induce  them  to  marry  them,  or  of  relatives  or  other  per- 
sons, who  influence  them  in  the  disposition  of  their  property. 

Primary  Dementia. 

As  has  been  already  stated,  this  may  occur  in  two  forms — 
i.  e.,  a  mild  or  a  severe,  called  respectively  confusional  insanity 
and  stuporous  insanity. 

It  has  been  defined  to  be  an  acute  insanity  produced  by  ner- 
vous shock  or  exhausting  disease,  without  distinct  constant 
emotional  depression  or  exaltation ;  with  marked  abatement 
of  mental  j)Ower  (ranging  from  a  mild  mental  confusion  to 
complete  imbecility) ;  often,  but  not  invariably,  accompanied 
by  hallucinations  and  mental  excitement ;  with  loss  of  physical 
power  ;  usually  disturbances  of  temperature  ;  the  whole  com- 
monly ending  in  complete  recovery  (H.  C.  Wood). 

It  may  be  caused  by  sudden  shock  or  great  emotional 
strain,  prolonged  anxiety,  dissipation,  acute  diseases,  such  as 
typhoid  fever,  influenza,  diphtheria,  etc.,  surgical  operations, 
and  childbirth. 

Confusional  insanity — symptoms :  The  patient  is  usually 
quiet  and  apathetic.  When  he  does  converse  there  is  marked 
incoherence,  there  being  inability  to  carry  out  any  line  of 
thought  to  a  conclusion.  The  following  conversation,  taken 
from  Spitzka's  Manual  of  Insanity,  is  characteristic  :  "  I  am, 
I — I  don't  know  that — I — is  dead — funerals  are — how  do 
you  do — met  you  in  Boston  steamer — tliis  is  London — Lon- 
don— I  am  sure  of  it — see  ! — I  have  not  forgotten  everything 
— there  are  not  so  many  now."  When  asked  what  lie  re- 
ferred to,  he  replied  :  The  police  of  London  have  their  rories 
to  watch — you  know,  to  watch — all  the  furniture — look  at 


DEMENTIA.  417 

that  horse — it  is  alive — it  is  not  a  wooden  horse — (it  was) — 
it  looks  so — I  think  it  is— my  poor  father — who  was  the 
eldest  son  of  my  nieee,"  etc. 

Hallucinations,  illusions,  and  delusions,  as  will  be  seen 
from  the  above,  are  present.  These  are  also  of  a  varied 
character,  being  depressive  at  one  moment,  exalted  at  another ; 
but  they  cause  no  corresponding  emotional  state.  Delusions 
of  identity  are  common.  The  patient  believes  that  he  is 
some  one  else  or  that  he  is  not  in  the  place  in  which  he  is. 
Another  frequent  delusion  is  that  some  one  is  in  bed  with 
him. 

Along  with  the  mental  symptoms  there  are  marked  physi- 
cal ones;  weight  is  lost,  the  temperature  is  frequently  sub- 
normal, the  pulse  rapid  and  weak,  and  the  muscular  strength 
greatly  reduced. 

Confusional  insanity — diagnosis:  The  disorder  may  be  mis- 
taken for  mania.  The  incoherence  of  mania  differs  from  that 
of  confusional  insanity  in  that  it  is  due  to  ideas  crowding  into 
the  brain  with  such  rapidity  that  they  cannot  be  expressed 
fast  enough.  That  of  the  latter  is  due  to  weakness  of  the 
mental  function,  and  is  present  whether  the  patient  speak  fast 
or  slow.  The  delusions  present  in  confusional  insanity  give 
rise  to  no  corresponding  emotional  state,  as  they  do  in  mania, 
and  there  is  not  the  physical  activity  which  is  present  in  that 
condition.  The  incoherence  present  will  enable  the  condition 
to  be  distinguished  from  melancholia. 

Stuporous  insanity — synonyms — symptoms  :  This  form  is 
also  known  as  acute  dementia  and  anergic  stupor.  It  fre- 
quently occurs  in  young  persons.  The  patient  is  completely 
passive,  doing  nothing  of  his  own  volition.  He  remains 
anywhere  he  is  put ;  but  the  muscles  are  relaxed  ;  hence  he  is 
not  cataleptic.  Sensibility  is  impaired,  and  the  reflexes  are 
diminished  or  absent.  Food,  even  when  placed  in  the  mouth, 
may  not  be  swallowed.  The  pupils  are  dilated,  the  pulse 
rapid  and  weak,  the  extremities  cold,  cyanotic,  and  often 
oedematous,  and  the  temperature  lowered.  The  urine  is  rich  in 
phosphates.  Menstruation  and  perspiration  are  abolished,  and 
Kaynaud's  disease  (p.  376)  sometimes  develops.  All  mental 
functions  a])pear  to  be  a])olished.  Fseces  and  urine  are  passed 
involuntarily  ;  the  saliva  dribbles  from  the  mouth  ;  and  slight 

27_N.  D. 


418  MENTAL  DISEASES. 

or  no  apparent  reaction  is  produced  by  any  sensory  stimu- 
lation. The  face  is  absolutely  expressionless.  There  may  be 
intervals  in  which  the  patient  speaks  a  few  words^  usually 
repetitions  of  something  said  in  his  presence. 

Stuporous  insanity — diagnosis :  The  diagnosis  may  have  to 
be  made  from  paranoia,  the  stuporous  form  of  melancholia, 
katatonia,  and  post-e|)ileptic  stupor.  A  paranoiac  acting  un- 
der a  delusional  command  may  remain  speechless  and  inactive ; 
the  facial  expression  will,  however,  betray  intelligence,  and 
investigation  will  disclose  the  existence  of  previous  hallu- 
cinations and  systematized  delusions. 

The  stuporous  form  of  melancholia  differs  in  the  muscular 
rigidity,  anxious  expression,  and  evidence  of  depressive  and 
non-systematized  delusions. 

The  distinguishing  features  of  katatonia  will  be  discussed 
later. 

A  history  of  epileptic  convulsions  occurring  just  previous 
to  the  development  of  stupor  will  distinguish  post-epileptic 
stupor.  The  previous  history  of  the  patient  will  be  of  great 
service  in  making  the  diagnosis. 

Primary  dementia — prognosis :  The  prognosis  in  both  con- 
fusional  and  stuporous  insanity  is  good,  recovery  occurring  in 
most  cases  in  from  a  few  weeks  to  a  few  months.  The  cases 
which  do  not  recover  either  pass  into  terminal  dementia  or 
die  from  exhaustion. 

Primary  dementia — treatment:  The  bodily  warmth  of  the  pa- 
tient must  be  maintained  by  means  of  hot- water  bags,  overheated 
rooms,  and  plenty  of  woollen  clothing.  When  the  body-temper- 
ature falls  below  97°  F.  means  should  at  once  be  employed  to 
restore  it.  The  patient  should  be  made  to  take  all  the  easily 
digested  and  nutritious  food  that  he  can  possibly  assimilate. 
If  food  is  refused,  it  should  be  administered  artificially,  as 
detailed  under  the  treatment  of  melancholia.  The  food 
should  be  given  at  frequent  intervals.  Wood  mentions  a  case 
that  took  daily,  for  weeks,  sixteen  raw  eggs  in  six  pints  of 
milk.  Absolute  rest  in  bed  must  be  insisted  upon  ;  and  mas- 
sage and  general  faradization,  according  to  the  strength  of 
the  patient,  should  be  used. 

The  drugs  to  be  given  consist,  first,  of  tonics,  such  as 
ascending  doses  of  strychnine,  phosphorus  in  small  doses. 


DEMENTIA.  419 

arsenic,  and  iron ;  and,  secondly,  if  there  is  insomnia,  of 
calmatives,  such  as  the  hot  pack,  hyoscine,  trional,  or  the 
cautious  use  of  chloral  or  the  bromides.  Opium  may  be  of 
service  in  some  cases. 

Paretic  Dementia. 

Synonyms — definition :  This  disease  is  known  also  as  pro- 
gressive general  paralysis,  general  paresis,  paresis,  general 
paralysis  of  the  insane,  chronic  diffuse  meningo-encephalitis, 
chronic  peri-encephalitis.  By  the  laity,  it  is  often  termed  soft- 
ening of  tiie  brain.  It  is  a  disorder  characterized  mentally 
by  a  progressive  enfeeblement  associated  with  either  exalted 
or  depressive  delusions,  or  both  alternately.  Physically  there 
is  also  progressive  enfeeblement,  often  associated  with  ataxia. 

Etiology :  Paretic  dementia  may  occur  at  any  time  from 
•childhood  to  old  age ;  but  it  appears  chiefly  between  the  ages 
of  thirty  and  fifty-five.  It  more  frequently  attacks  the  male 
sex.  According  to  Miekle,  they  are  attacked  about  four  times 
as  often  as  the  female.  A  neuropathic  heredity  may  act  as 
a  predisposing  cause.  Probably  tlie  most  frequent  etiological 
factor  is  syphilis,  variously  estimated  by  different  authorities 
to  be  the  cause  in  from  60  to  90  per  cent,  of  the  cases.  When 
due  to  syphilis,  it  is  a  parasyphilitic  disease  (see  Syphilis  of 
the  Nervous  System).  Other  causes  are  alcoholism,  excessive 
venery,  prolonged  mental  overstrain  and  excitement,  pro- 
longed and  exhausting  physical  work.  Two  or  more  of  these 
causes  may  act  together,  especially  prolonged  mental  or  physi- 
cal strain  in  connection  with  either  syphilis  or  alcoholism,  or 
both. 

Symptoms :  In  rare  instances  paretic  dementia  may  be- 
gin suddenly  with  an  epileptiform  or  apoplectiform  seizure, 
which  is  followed  by  rapid  development  of  the  characteristic 
symptoms.  In  the  great  majority  of  instances  the  mode  of 
onset  is  gradual,  constituting  a  prodromal  stage  of  greater  or 
less  duration.  Tliere  will  be  noticed  changes  in  the  charac- 
ter of  the  patient ;  for  instance,  from  a  man  of  good  habits 
and  regular  mode  of  life,  he  becomes  intemperate,  licentious, 
neglects  his  business,  and  spends  money  faster  than  his  income 
warrants.     He  is  moody  and  irritable  and  spells  of  depression 


420  MENTAL  DISEASES. 

may  also  occur.  Failure  of  memory  will  be  noted  and  in- 
somnia, and  a  ravenous  appetite  are  frequent  in  this  stage. 
While  these  symptoms  of  themselves  are  not  sufficient  to 
make  the  diagnosis  of  paretic  dementia,  they  should  awaken 
strong  suspicions  when  they  are  present  in  a  person  liable  to 
develop  the  disease. 

The  symptoms  of  the  second  stage,  or  developed  disease,  are 
both  mental  and  physical.  The  usual  mental  condition  is  one 
of  a  more  or  less  marked  feeling  of  exaltation  or  maniacal 
condition ;  he  becomes  restless  and  irritable,  insomnia  is 
present,  and  the  so-called  delusions  of  grandeur  develop.  For 
instance,  he  believes  himself  to  be  possessed  of  untold  wealth, 
to  be  the  strongest  man  in  the  world,  a  great  pugilist,  or  is 
going  to  engage  in  some  enormous  business  enterprise. 

In  place  of  delusions  similar  to  those  mentioned  there  may 
be  merely  a  feeling  of  well-being  and  indifference.  When  asked 
how  he  is,  the  answer  will  always  be  "first-rate,"  or  that  "he 
feels  well."  While  he  may  be  a  poor  man,  the  fact  that  he  is 
unable  to  work  and  support  his  family  does  not  worry  him. 

In  some  cases,  instead  of  the  exalted  condition,  the  patient 
becomes  depressed,  hypochondriacal,  and  may  apparently 
appreciate  and  worry  about  his  condition.  In  other  cases 
there  may  be  alternate  periods  of  exaltation  and  depi'ession. 
Hallucinations,  if  they  occur,  are  exceedingly  rare. 

The  physical  sy7n2)toms  are  of  great  importance  in  arriving 
at  a  diagnosis.  One  of  the  earliest  to  be  noticed  is  disturb- 
ance of  the  speech.  This  is  slow,  interrupted,  and  slurred, 
resembling  somewhat  that  of  a  drunken  man.  Special  diffi- 
culty is  encountered  in  pronouncing  labials  and  Unguals  and 
the  inability  to  pronounce  test-phrases  and  sentences,  as 
"truly  rural/'  "legal  intelligences,"  "  Peter  Piper  picked  a 
peck  of  pickled  peppers,"  etc.,  is  among  the  earl}^  evidences 
of  the  disease.  Tremor  of  the  muscles  of  the  face,  especially 
of  the  lips  and  of  the  hands,  will  be  noticed.  Owing  to  the 
latter  condition,  writing  becomes  difficult  or  impossible.  The 
tongue  is  also  tremulous  and  is  protruded  with  difficulty,  and 
when  protruded  cannot  be  kept  so.  The  expression  of  the 
face  is  stolid  and  the  facial  lines  are  smoothed  out.  General 
muscular  weakness  and  inability  for  exertion  will  be  found, 
although  the  patient  will  assert  the  contrary.     The  knee-jerk 


DEMENTIA.  421 

may  be  increased,  normal,  diminished,  or  lost.  The  pupils 
are  usually  unequal,  and  present  the  Argyll-Robertson  phe- 
nomenon. Degeneration  of  the  optic  nerve  also  may  occur. 
There  is  often  more  or  less  marked  ataxia.  In  fact,  all  the 
characteristic  symptoms  of  tabes  may  either  follow  or  precede 
the  development  of  paresis.     The  appetite  continues  ravenous. 

During  the  progress  of  the  disease,  epileptiform,  apoplecti- 
form, or  by  steroidal  seizures  may  occur.  The  former  are 
usually  mild,  and  the  convulsive  movements  are  limited  to  the ' 
face  and  arm  of  one  side.  They  may,  however,  be  severe, 
and  sometimes  cause  death.  The  apoplectiform  seizures  may 
consist  of  coma,  facial  congestion,  elevated  temperature,  and 
temporary  hemiplegia ;  or  transient  paralysis  may  occur 
without  loss  of  consciousness. 

Remissions  in  the  symptoms  may  occur,  and  it  may  be 
thought  that  recovery  is  going  to  ensue ;  but  they  return,  and 
progress  until,  if  death  does  not  occur,  the  Jinal  stage  is 
reached. 

In  this  the  dementia  becomes  absolute,  the  patient  becomes 
weaker  and  weaker,  and  finally  bedridden ;  bedsores  and 
paralysis  of  the  bladder  and  rectum  develop,  and  finally  death 
occurs. 

Paretic  dementia — morbid  anatomy :  The  macroscopical 
changes  are :  Increase  of  the  cerebro-spinal  fluid ;  oedema 
of  the  pia ;  chronic  leptomeningitis,  the  membranes  being 
thickened  and  opaque  and  adherent  to  the  cortex.  In  about 
50  per  cent,  of  the  cases  pachymeningitis  hsemorrhagica  in- 
terna is  also  present.  The  ventricles  are  sometimes  found  to 
be  dilated  and  distended  with  serum,  while  a  granular  condi- 
tion of  the  ependyma  is  a  constant  and  characteristic  change. 
There  is  diminution  in  the  weight  of  the  brain,  and  the  con- 
volutions are  atrophied  and  the  fissures  patulous,  especially  in 
the  frontal  and  parietal  regions.  The  cortex  in  color  is 
either  extremely  pale  or  is  of  a  marked  rosy  tint,  due  to 
congestion  of  the  small  bloodvessels.  Areas  of  softening  or 
hemorrliage,  due  to  arterio-sclerosis,  are  frequently  found 
scattered  throughout  the  brain.  In  consistency  the  cortex 
may  be  either  softer  than  normal ;  or  firmer,  due  to  sclerosis, 
These  different  conditions  may  be  found  in  the  same  brain, 
the  latter  probably  being  the  ultimate  result  of  the  former. 


422  MENTAL  DISEASES. 

Sclerotic  changes  are  also  found  in  the  pons,  medulla,  and 
frequently  in  the  posterior  and  lateral  columns  of  the  cord. 
As  has  already  been  said,  tabes  may  either  follow  or  precede 
the  development  of  paretic  dementia. 

MiorosGopieaUy,  in  tracing  the  changes  in  the  cortex  we 
have  three  well-marked  steps  defined,  which  have  been  sum- 
marized by  Bevan  Lewis  ^  as  follows  : 

1.  A  stage  of  inflammatory  change  in  the  tunica  adventitia, 
with  excessive  nuclear  proliferation,  profound  changes  in  the 
vascular  channels,  and  trophic  changes  induced  in  the  tissues 
around. 

2.  A  stage  of  extraordinary  development  of  the  lymph- 
connective  system  of  the  brain,  with  a  parallel  degeneration 
and  disappearance  of  nerve-elements,  the  axis-cylinders  of 
which  are  denuded. 

3.  A  stage  of  general  fibrillation,  with  shrinking  and  ex- 
treme atrophy  of  the  parts  involved. 

Diagnosis  :  Paretic  dementia  may  be  confounded  with  neur- 
asthenia ;  the  mental  changes  produced  by  chronic  alcoholism 
and  plumbisra ;  cerebral  syphilis ;  secondary  paranoia  with 
delusions  of  grandeur;  multiple  sclerosis;  bulbar  palsy  ;  and 
dementia  associated  with  organic  diseases  of  the  brain — viz., 
tumor  and  apoplexy. 

It  resembles  neurasthenia  only  in  the  early  or  prodromal 
stage,  when  the  symptoms  may  be  very  similar.  The  oc- 
currence of  such  symptoms  in  a  previously  healthy  man  who 
has  been  exposed  to  any  of  the  etiological  factors  of  paresis 
should  awaken  suspicion,  especially  if  he  becomes  absent- 
minded,  negligent  of  his  business,  irritable,  exhibits  loss  of 
attention,  concentration,  and  judgment,  and  increase  of  sexual 
power. 

Chronic  aleohoUsm  may  present  many  of  the  sym])toms  of 
paresis — i.  e.,  tremor,  thick  speech,  and  dementia.  Often  it  is 
only  by  the  improvement  that  occurs  after  the  withdrawal  of 
the  alcohol  that  the  diiferential  diagnosis  can  be  made.  Cere- 
bral disorder  due  to  chronic  lead-poisoning  may  imitate  closely 
the  facial  expression,  tremor,  etc.,  of  the  paretic.  A  history 
of  exposure  to  the  poison  and  the  presence  of  other  evidences 

^  Mental  Diseases,  2d  ed.,  p.  552. 


DEMENTIA.  423 

of  lead-poisoiiing  (blue  line,  neuritis)  would  distinguish  the 
former. 

Cerebral  syphilis  may  simulate  paresis  more  closely  than 
any  other  aifection.  The  distinction  may  often  be  impossible 
except  by  noting  the  effects  of  specific  treatment.  The  fol- 
lowing differential  ])oints  are  abstracted  from  a  paper  on  this 
subject  by  Patrick  :  ^  When  the  symptoms  appear  at  a  remote 
period  (after  ten  years)  after  infection  the  disorder  is  probably 
paresis.  If  they  appear  within  a  few  years  (one  to  ten  years) 
after  infection,  the  probabilities  are  in  favor  of  cerebral 
syphilis.  In  paresis  the  early  or  prodromal  symptoms  are 
disturbances  of  the  higher  mental  functions.  The  higher 
faculties  being  first  attacked,  the  mental  acts  of  routine  ex- 
istence that  have  become  nearly  automatic  are  impaired  last : 
thus,  a  man  may  be  able  to  conduct  his  own  business  for  some 
time  after  he  has  exhibited  much  impairment  of  the  ability 
to  perform  other  mental  acts.  In  cerebral  syphilis  these 
symptoms  are  usually  somatic,  as  paralyses  in  various  situa- 
tions, usually  focal,  sensory  disturbances,  etc.  In  cerebral 
syphilis,  therefore,  there  are  apt  to  be  symptoms  added  to  the 
clinical  picture  that  are  not  usual  in  paresis. 

Severe  headache  is  practically  always  present  in  syphilis ; 
practically  absent  in  paresis.  Some  headache  may  occur  in 
the  early  stages  of  paresis,  but  not  the  characteristic  pain  of 
cerebral  syphilis. 

Pains  in  other  parts  of  the  body,  worse  at  nights,  are  char- 
acteristic of  syphilis,  and  against  paresis. 

Marked  anaesthesia  or  parsesthesia  is  much  more  frequent 
in  syphilis. 

Paralyses  of  any  of  the  cranial  nerves,  below  the  third,  are 
in  favor  of  syphilis.  While  the  third  nerve  may  be  also  affected 
in  paresis,  there  are  differences  which  assist  in  the  diagnosis 
— viz.,  Argyll-Robertson  pupil  is  .strongly  indicative  of 
iparesis.  Either  complete  immobility  of  the  pupil  (internal 
■ophthalmoplegia)  or  external  ophthalmoplegia  is  indicativ^e  of 
syphilis.  Association  of  paralysis  of  the  third  nerve  with 
^that  of  other  cranial  nerves  is  indicative  of  syphilis. 

The  physical  weakness,  tremor,  etc.,  occurring  in  paresis 

■^  Points  of  Distinction  between  Cerebral  Syphilis  and  General  Paralysis 
(bf  the  Insane.     N.  Y.  Med.  .Jour.,  vol.  Iviii.  p.  256  et  seq. 


424  MENTAL  DISEASES. 

are  generalized.  Any  symjjtoms  pointing  to  a  localized  or 
focal  brain  lesion  wonld  indicate  syphilis.  When  localized 
paralyses  do  occur  in  paresis  they  usually  follow  one  of  apo- 
plectic attacks,  which  occur  in  the  course  of  the  disease,  and 
in  the  great  majority  of  instances  are  transient. 

Primary  optic  atrophy  is  a  symptom  of  paresis.  Optic 
neuritis  and  secondary  atrophy  are  indicative  of  syphilis. 

Persistent  yawning,  if  there  are  no  signs  of  bulbar  disease, 
indicates  paresis. 

Marked  loss  of  weight  often  occurs  in  the  early  stages  of 
syphilis.  In  paresis,  excepting  in  the  advanced  stages,  this 
is  very  rare. 

The  presence  of  polydipsia,  polyuria,  or  vomiting  of  the 
cerebral  type  would  most  likely  be  due  to  syphilis.  The 
mental  state  following  an  epileptiform  seizure  may  be  of  assist- 
ance. In  paresis  this  is  always  distinctly  worse  ;  but  in  syphi- 
lis such  is  not  usually  the  case.  If  in  the  early  stage  there  are 
mental  eagerness  and  restlessness,  a  hyperactivity  without 
hyperacuity,  increase  of  sexual  desire  and  po^vcr;  or  if,  in- 
stead of  the  above,  there  is  a  long  period  (one  to  five  years) 
of  prodromal  symptions  resembling  neurasthenia,  the  disease 
is  paresis.  Either  marked  delusions  of  grandeur  or  exagger- 
ated hypochondriacal  delusions  very  rarely  occur  in  cerebral 
syphilis.  The  condition  of  contentment,  and  "  being  pleased 
with  one's  self,"  spoken  of  under  symptomatology,  is  more 
common  in  syphilis,  but  is  also  frequent  in  paresis. 

Secondary  paranoia  would  be  distinguished  by  a  history  of 
previous  acute  mania  and  the  absence  of  the  physical  symp- 
toms characteristic  of  paresis.  Multi]ile  sclerosis,  bulbar 
palsy,  and  dementia  due  to  organic  brain  disease  could  hardly 
be  confounded  with  paresis  if  careful  attention  is  paid  to  the 
history  of  the  mode  of  onset  and  the  symptoms  carefully 
investigated. 

Prognosis  :  Paretic  dementia  usually  runs  its  course  in  from 
three  to  five  years,  the  ultimate  result  being  death.  Rarely, 
cases  may  last  longer  than  this. 

Paretic  dementia — treatment :  The  effects  of  antisyphilitic 
treatment  may  at  first  be  given  a  fair  trial.  If  no  benefit  is 
experienced  from  this,  committal  to  an  asylum  should  be  in- 
sisted upon. 


EPILEPTIC  INSANITY.  425 

INSANITIES  DUE  TO  SPECIAL  CAUSES. 

While  probably  all  tbriiis  of  insanity,  due  to  whatever 
cause,  can  be  classiiled  in  one  of  the  forms  just  described, 
there  are  some  due  to  special  causes  which  possess  some  dis- 
tino;uishing  features.  The  more  important  of  these  will  be 
now  described  : 

EPILEPTIC  INSANITY. 

Definition — varieties :  This,  as  its  name  implies,  is  the 
mental  derangement  which  may  occur  in  epileptics.  It  has 
been  estimated  that  10  per  cent,  of  all  epileptics  become  in- 
sane. Various  forms  occur — /.  e.,  transitory,  stuporous,  and 
hallucinatory  disorders,  mania,  melancholia,  circular  insanity, 
and  finally  dementia,  Peterson  makes  the  following  classi- 
fication :  acute  transitory  epileptic  insanity,  chronic  epileptic 
insanity,  psychic  degeneration  of  epileptics,  and  epileptic 
dementia. 

Acute  transitory  epileptic  insanity  :  This  may  occur  before, 
after,  or  in  place  of  a  convulsion.  The  duration  of  the  at- 
tack may  vary  from  a  few  hours  to  several  days.  Tlie  symp- 
toms are  various.  Consciousness  may  be  entirely  lost,  but 
usually  the  state  is  one  of  partial  iniconsciousness.  Asso- 
ciated with  this  there  may  be  hallucinations,  usually  of  a 
terrifying  nature,  but  they  may  be  pleasant;  delirium;  in- 
coherence; delusions,  often  those  of  persecution  ;  destructive- 
ness  ;  impulses  to  commit  assaults,  homicide,  or  suicide.  In 
some  cases  the  ])atient  remains  in  a  stuporous  condition,  broken 
by  intervals  oi^  violence  or  religious  ecstacy.  Upon  recovery 
there  is  either  absolute  loss  of  memory  as  regards  everything 
that  has  taken  place ;  or  there  is  complete  amnesia  at  first, 
with  recollection  of  some  events  that  occur  as  the  condition 
is  passing  off.  In  this  it  differs  from  acute  mania  or  melan- 
cholia, in  whicli  there  is  usually  some  and  often  complete 
recollection  of  what  has  occurred  during  the  attack. 

According  to  Peterson,  the  epileptic  nature  of  such  states, 
when  the  history  is  not  known,  may  be  suspected  by  the  fol- 
lowing characteristics  :  (1)  sudden  onset  and  abrupt  termina- 
tion ;  (2)  the  terrifying  or  ecstatic  nature  of  the  delusions 
and    hallucinations;    (3)    disturbance    of   consciousness   and 


426  MENTAL  DISEASES. 

stuporous  conditions ;  (4)  impulsive  acts ;  (5)  dream  states ; 
(6)  amnesia. 

Chronic  epileptic  insanity :  Epileptic  automatism  has  already 
been  described  (see  Epilepsy).  The  condition  above  de- 
scribed may  take  a  chronic  course,  and  resemble  either  chronic 
mania,  melancholia,  or  circular  insanity.  Such  occurring  in 
an  epileptic  would  be  the  distinguishing  feature. 

Psychic  degeneration  :  The  epileptic,  in  proportion  to  the 
frequency  and  severity  of  the  seizures,  suffers  a  gradual 
failure  of  mental  power.  Memory  is  impaired,  ideation  and 
expression  are  sluggish,  the  judgment  is  defective.  He  is 
also  apt  to  become  irritable  and  brutal,  and  control  over  the 
passions  is  lost.  During  this  period,  attacks  such  as  above 
described  (acute  transitory  insanity)  may  occur.  The  ulti- 
mate termination,  if  death  does  not  occur  before,  is  complete 
dementia.     Of  coui^se,  this  condition  is  incurable. 

The  treatment  is  that  of  epilepsy  in  general.  Of  course, 
the  tendency  to  the  commission  of  deeds  of  violence  must  be 
remembered,  and  it  is  well  to  commit  epileptics  subject  to 
attacks  of  insanity  to  an  asylum. 


ALCOHOLIC  INSANITY. 

This  is  also  manifested  in  various  forms,  and  may  be  acute 
or  chronic. 

Acute  alcoholic  insanity — symptoms  :  This  usually  assumes 
the  form  familiarly  known  as  delirium  tremens,  or  mania-a- 
potu.  The  symptoms  may  develop  after  a  sudden  cessation 
of  the  use  of  stimulants  or  come  on  during  a  debauch. 

The  mental  symptoms  in  mild  cases  are  :  mental  confusion, 
depression  of  spirits,  forebodings  of  evil,  and  a  sense  of  terror, 
with  possibly  hallucinations  at  night. 

In  severe  attacks,  hallucinations,  especially  of  sight  and 
hearing,  are  marked  and  constant.  These  are  always  of  a  hor- 
rible and  terrifying  nature.  Thus  the  patient  sees  disgusting 
objects,  or  hears  voices  predicting  evil,  punishment,  etc.  While 
these  patients  may  be  violent,  it  is  due  to  terror  and  an  effort 
to  defend  themselves.  The  physical  symptoms  are  character- 
isticj  and  consist  of  marked  tremor,  physical  weakness,  insom- 


ALCOHOLIC  INSANITY.  427 

nia,  loss  of  appetite^  and  often  weakened  heart's  action. 
Pneumonia  is  apt  to  occur. 

Acute  alcoholic  insanity — diagnosis — prognosis  :  The  pecu- 
liar character  of  the  hallucinations,  combined  with  the  tremor, 
is  characteristic. 

While  most  of  these  cases  recover,  in  broken-down  indi- 
viduals or  in  those  whose  hearts  are  weak,  death  often  occurs. 
Pneumonia  is  a  very  dangerous  complication.  Some  cases 
may  pass  into  the  chronic  condition  described  below. 

Treatment :  In  treating  such  a  case  the  first  indication  is 
the  elimination  of  the  poison.  If  there  has  been  alcohol 
taken  recently  and  the  patient  is  in  good  physical  condition, 
an  emetic  may  be  given.  In  all  cases  a  purgative,  preferably 
calomel,  is  essential,  and  measures  to  increase  action  of  the 
skin  and  kidneys  are  of  service. 

It  is  essential  to  induce  sleep.  To  this  end  the  bromides, 
combined  with  chloral,  chloral  and  morphine,  paraldehyde, 
and  other  hypnotics,  may  be  used.  Large  doses  of  these 
remedies  are  often  essential,  but  when  used  their  effects  must 
be  carefully  watched.  If  during  the  day  there  is  much  rest- 
lessness and  nervous  excitement,  bromides  should  be  given  at 
regular  intervals. 

In  the  majority  of  cases  the  use  of  alcohol  in  all  forms 
should  be  stopped  at  once  ;  but  in  old  people,  or  in  those 
whose  circulation  is  very  feeble,  it  may  be  necessary  to  admin- 
ister it  and  gradually  reduce  the  amount.  The  use  of  full 
doses  of  strychnine  is  advisable.  If  the  heart  is  very  weak, 
digitalis  should  also  be  given. 

Nutritious  and  easily  digested  food,  consisting  of  milk  ; 
strong  broths,  highly  seasoned  with  capsicum  ;  soft-boiled 
eggs,  etc.,  must  be  given  as  freely  as  can  be  digested. 

If  the  patient  is  very  violent  and  cannot  be  controlled,  it 
may  be  necessary  to  restrain  him  by  securing  his  person  to 
the  bed  by  straps  or  otherwise. 

Chronic  alcoholic  insanity — symptoms :  Those  who  have 
used  alcohol  excessively  and  for  a  long  period  may  develop 
gradual  loss  of  memory,  weakening  of  the  power  of  attention 
and  the  will,  and  mental  confusion.  The  patient  is  given  to 
periods  of   depression ;    becomes  suspicious ;    terrifying  and 


428  MENTAL  DISEASES. 

disagreeable  hallucinations  develop,  and  finally  delusions  of 
a  depressive  nature.  These  are  especially  apt  to  relate  to  tlie 
sexual  organs,  and  marital  infidelity. 

As  has  been  before  stated,  there  is  also  a  form  of  derange- 
ment due  to  alcohol  which  is  associated  with  expansive  delu- 
sions, especially  apt  to  relate  to  religious  matters,  hallucina- 
tions, and  tremor,  which  closely  resembles  paretic  dementia. 

Chronic  alcoholic  insanity — prognosis  :  The  usual  termina- 
tion of  these  cases  is  in  dementia ;  but  if  alcohol  is  with- 
drawn, and  they  are  placed  upon  proper  treatment  and 
hygienic  measures,  they  may  improve.  From  the  nature  of 
the  delusions,  such  cases  are  better  in  an  asylum. 

Treatment  consists  of  the  withdrawal  of  alcohol,  a  regular 
mode  of  life,  attention  to  the  bowels  and  other  excretory 
organs,  the  promotion  of  sleep,  and  the  administration  of 
large  doses  of  strychnine. 

HYSTERICAL  INSANITY. 

Symptoms :  The  victim  of  hysteria  may  develop  symptoms 
which  indicate  a  degree  of  mental  aberration  properly  classi- 
fied under  insanity.  These  symptoms,  which  are  character- 
istic, have  been  well  described  by  Folsora,  as  follows : 
"  It  is  characterized  by  extreme  and  rapid  mobility  of  the 
mental  symptoms — amnesia,  exhilaration,  melancholic  de- 
pression, theatrical  display,  suspicion,  distrust,  prejudice,  a 
curious  combination  of  truth  and  more  or  less  unconscious 
deception,  with  periods  of  mental  clearness  and  sound  judg- 
ment which  are  often  of  greater  degree  than  is  common  in 
their  families  ;  sleeplessness,  distressing  and  grotesque  hallu- 
cinations of  sight,  distortion  and  perversion  of  facts  rather 
than  definite  delusions ;  visions,  hyperesthesias,  anaesthesias, 
paresthesias ;  exceeding  sensitiveness  to  light,  touch,  and 
sound ;  morbid  attachments,  fanciful  beliefs,  an  unhealthy 
imagination ;  abortive  or  sensational  suicidal  manoeuvres, 
occasional  outbursts  of  violence ;  a  curious  combination  of 
unspeakable  wretchedness  alternating  with  joy,  generosity, 
and  selfishness — of  gifts  and  graces  on  the  one  hand  and  ex- 
actions on  the  other.  The  mental  instability  is  like  a  vane 
veered  by  loving  zephyrs.     The  most  trifling  causes  start  a 


HEBEPHRENIA.  429 

mental  whirlwind.  There  is  no  disease  giving  rise  to  more 
o-enuine  suifering  or  appealing  more  strongly  for  sympatliy. 
Yet  when  this  is  freely  given  it  does  harm.  One  such  person 
in  the  house  wears  out  and  outhves  one  after  another  every 
healthy  member  of  the  family  who  is  unwisely  allowed  to 
devote  lierself  with  conscientious  zeal  to  the  invalid." 

As  will  be  seen  from  the  above  description,  the  diagnosis 
is  based  upon  the  ever-changing,  shifting  character  ol  the 
symptoms  associated  with  some  of  the  stigmata  of  hysteria. 

Restraint  may  be  sometimes  necessary,  otherwise  the  treat- 
ment is  that  of  hysteria  in  general. 

HEBEPHRENIA. 

Definition:  Hebephrenia,  also  known  as  the  insanity  of 
pubescence  and  masturhatlonal  inmnity,  is  defined  by  Spitzka 
to  be  a  form  of  insanity  character! ze<l  by  mental  enfeeble- 
ment  marked  by  a  silly  disposition,  following  a  prelnninary 
period  of  depression,  which  has  the  same  tinge  as,  without 
the  depth  of,  that  characterizing  melancholia,  and  which  coin- 
cides with  or  folloNvs  the  period  of  ])uberty.  Hebephrenia 
occurs  in  neuropathic  subjects,  and  H.  C.  Wood  classifies  it 
with  paranoia;  but  it  is  not  so  considered  by  most  au- 
thorities. , 

Symptoms:  At  the  time  of  puberty,  children,  especiallv 
boys,  exhibit  various  peculiarities.  They  are  sentimental  and 
egotistical.  In  most  instances,  as  manhood  develops,  these 
peculiarities  disappear ;  but  in  neuropathic  individuals  they 
do  not,  but  become  exaggerated,  and  hebephrenia  develops. 

As  indicated  by  its  definition,  hebephrenia  appears  between 
the  ages  of  fifteen  and  twenty  years.  It  begins  with  a  period 
of  depression  or  sadness,  during  which  suicidal  attempts  may 
be  made.  The  patients  are  anxious  to  talk  about  their  suffer- 
ings to  others,  in  which  they  differ  from  those  suffering  from 
melancholia;  and  at  intervals  during  this  period  they  may 
have  spells  of  causeless  laughter  or  make  silly  jokes.  lo 
awaken  interest  in  themselves,  they  may  simulate  various 
disorders.  After  this  period  passes  off  they  become  restless, 
have  no  fixed  purpose,  trying  first  one  business,  then  another. 
They  often  think  that  they  have  talents  which  are  not  appre- 


430  MENTAL  DISEASES. 

ciated  as  they  should  be.  There  is  a  marked  tendency  to  use 
big  words  and  foreign  expressions ;  to  be  verbose  or  quote 
poetry. 

The  victims  of  this  disorder  are  apt  to  be  excessive  mas- 
turbators,  which,  however,  is  due  to,  and  not  the  cause  of,  the 
mental  condition. 

The  course  of  this  form  of  insanity  is  protracted,  and  in 
time  the  patient  passes  into  a  terminal  dementia  marked  by 
occasional  outbreaks  of  excitement. 

Partially  developed  forms,  those  in  which  the  disturbance 
is  manifested  by  a  tendency  to  write  silly  and  sentimental 
poetry  and  a  slightly  strained  emotional  condition,  may  re- 
cover. 

Treatment :  Such  patients  will  probably  do  better  if  treated 
in  an  asylum  than  at  Jiome. 

PUERPERAL  INSANITY. 

Definition  :  This  term  has  been  applied  to  insanity  occur- 
ring in  women  during  the  period  of  pregnancy  or  after  de- 
livery. It  may  appear  within  a  few  days  or  several  weeks 
after  confinement  or  during  lactation.  The  disease  may  mani- 
fest itself  either  in  the  form  of  melancholia  or  mania.  That 
which  occurs  during  pregnancy  usually  takes  the  form  of  de- 
pression ;  that  occurring  post-partum  is  usually  maniacal  or 
confusional  in  form. 

Etiology :  The  worry,  physical  and  mental  strain  which 
attend  these  states  are,  as  has  already  been  said,  prominent 
causes  of  the  development  of  mania,  confusional  insanity,  and 
melancholia.  Septic  poisoning  is  also  a  frequent  cause  of 
post-partum  insanity ;  and  the  introduction  of  aseptic  and 
antiseptic  measures  in  the  treatment  of  the  parturient  woman 
has  been  attended  with  a  marked  decrease  in  the  number 
of  cases  of  this  form. 

The  symptoms  in  general  are  those  of  melancholia,  mania,  or 
confusional  insanity,  more  or  less  severe,  as  the  case  may  be. 

Prodromal  symptoms  are  practically  absent,  the  onset 
being  rapid.  Tliere  is  often  a  marked  tendency  to  commit 
suicide,  to  the  infliction  of  self-injuries  or  mutilation,  or  to 
some  act  of  violence    to  the  child.     The    patients   are    also 


KATATONIA.  431 

usually  very  suspicious  of  persous  and  food,  and  often  refuse 
to  take  food.     The  temperature  may  or  may  not  be  elevated. 

Puerperal  insanity — prognosis  :  While  puerperal  insanity  is 
always  a  serious  complication,  if  the  temperature  and  pulse 
are  not  elevated  and  food  is  taken,  the  prognosis  is  favor- 
able ;  but  if  the  temperature  and  pulse  are  elevated,  and 
if  there  develop  refusal  to  take  food,  coated  and  dry  tongue, 
much  mental  confusion  and  delirium,  the  outlook  is  very 
serious.  Recovery,  when  it  occurs,  takes  place  usually  in  from 
three  to  five  months. 

Treatment :  When  the  physical  condition  of  the  patient  will 
permit,  removal  to  an  asylum  is  the  best  procedure  ;  but  if  the 
patient  is  very  weak,  treatment  had  better  be  carried  out  at 
home,  at  least  until  there  is  some  improvement  in  this  respect. 
In  view  of  the  nature  of  the  symptoms,  the  patient  must  be 
closely  watched.  Sleep  should  be  induced  by  methods  already 
detailed  (see  Mania),  and  plenty  of  digestible  and  nutritious 
food  administered.  If  there  is  refusal  to  take  it,  forced  feed- 
ing must  be  employed  (see  Melancholia).  Tonics  and  stimu- 
lants should  also  be  administered  as  required. 

KATATONIA. 

Definition :  This  rare  disorder  is  by  some  authorities  consid- 
ered to  be  a  distinct  form  of  insanity.  Others  do  not  believe 
this,  but  regard  it  as  a  modification  in  the  course  of  melan- 
cholia. It  has  been  defined  by  Spitzka  to  be  "  a  form  of  insanity 
characterized  by  a  pathetical  emotional  state  and  verbigeration, 
combined  with  a  condition  of  motor  tension." 

Symptoms :  The  condition  begins  with  an  initial  stage  pos- 
sessing the  features  of  ordinary  melancholia.  This  may  or 
may  not  be  followed  by  alternating  periods  of  atony  ;  excite- 
ment of  a  peculiar  type,  confusion,  and  depression,  which  may 
finally  merge  into  a  condition  of  more  or  less  marked  dementia. 

During  the  excited  stage  some  patients  present  exaggerated, 
others  diminished  self-esteem.  They  are  apt  to  be  fond  of 
exhibiting  declamatory  gestures  and  theatrical  behavior.  Often 
they  wander  about  imitating  preachers  and  actors,  and  may 
endeavor  to  become  such. 

Verbigeration,  or  an  uncontrollable  and  frequent  repetition 


432  MENTAL  DISEASES. 

of  the  same  word,  sentence,  or  sound,  is  a  characteristic  symp- 
tom of  this  disorder.  Thus  a  patient  of  Peterson's  would 
recite  all  day  long  an  infinite  variety  of  rhymes  of  unintelli- 
gible words  such  as  "  Tabies,  gabies,  habies,  sabies,  labies, 
niabies,"  etc.,  or  "  Moccasins,  noccasins,  doccasins,  crocka- 
sins,"  etc.  At  another  period  of  the  disease  she  would  con- 
tinually repeat  the  sentence  :  "  Bring  nie  home  to  my  children 
in  New  York,"  accompanying  this  with  theatrical  gestures. 

Hallucinations  of  a  depressive  character  are  freqnent.  The 
occurrence  of  cataleptic  periods  is  another  peculiar  feature. 
They  may  for  a  long  time  be  in  a  condition  resembling  that 
of  melancholia  attonita.  The  limbs  remain  in  any  position 
in  which  they  are  put. 

Occipital  headache  is  said  to  be  a  frequent  symptom. 

Katatonia — prognosis  :  The  prognosis  as  regards  life  is  good ; 
as  regards  return  to  mental  liealth  it  is  not  so  good.  There 
is  usually  in  patients  presenting  this  syndrome  a  slow  but 
sure  progress  toward  terminal  dementia. 

The  treatment  is  the  same  as  that  emj)loyed  for  melancholia. 


EXAMINATION   OF   THE   INSANE. 

In  examining  a  supposedly  insane  person  two  things  should 
be  determined  :  first.  Is  he  insane  ?  and,  second,  if  so.  Should 
he  be  treated  in  a  hospital  for  the  insane  or  at  home? 

When  possible,  the  physician  should  endeavor  to  ascertain 
from  the  family  or  elsewliere  the  habits  and  the  previous  men- 
tal and  physical  condition  of  the  patient,  and  in  what  manner 
he  has  departed  from  that  standard  ;  the  causes  for  such  de- 
parture, and  the  existence  of  mental  or  nervous  diseases  in 
other  members  of  the  family  or  previously  in  the  patient. 

In  examining  the  patient  the  condition  of  his  physical 
health  should  be  carefully  investigated — viz.,  condition  of 
circulation  ;  presence  of  choreiform  movements,  of  tremors ; 
irregularities  of  the  pupils  ;  character  of  the  speech  ;  temper- 
ature ;  the  reflexes ;  presence  of  emaciation ;  ataxia ;  motor 
paralysis ;  condition  of  the  digestive  organs,  etc. 

Particular  attention  should  also  be  paid  to  the /ac*a/  expres- 
sion, whether  apathetic,  restless,  friglitened,  etc. 


EXAMINATION  OF  THE  INSANE.  433 

Whether  food  is  taken  or  not  and  in  what  quantities,  and 
whether  insomnia  exists  or  not. 

By  conversation  witli  the  patient  we  determine  if  the  mem-  ■ 
ory  has  failed  both  for  past  and  recent  events ;  whether  inco- 
herence and  mental  confusion  exist ;  and  learn  the  exist- 
ence of  hallucinations,  delusions,  simple  depression,  or  exalta- 
tion. It  may  take  some  time  and  tact  to  determine  these 
facts,  and  more  than  one  visit  may  be  necessary. 

Removal  to  a  hospital :  Having  determined  that  insanity 
exists,  it  is  next  necessary  to  decide  as  to  the  advisability  of 
removal  to  a  hospital. 

If  the  patient  has  means,  is  not  suicidal,  homicidal,  nor  the 
victim  of  delusions  that  make  him  dangerous  to  himself  and 
others,  treatment  at  home  may  be  effectual.  When  the  patient 
is  poor  or  the  symptoms  mentioned  above  are  present,  removal 
to  a  hospital  is  the  best  and  safest  plan  both  for  the  patient 
and  the  community. 

Feigned  Insanity. 

Insanity  is  sometimes  feigned,  especially  by  those  charged 
with  crime  or  who  have  already  been  convicted.  The  object 
for  so  doing  is  apparent. 

Mania,  melancholia,  and  dementia  are  the  usual  forms  simu- 
lated. 

In  examining  such  a  case  it  must  be  remembered  that  each 
form  of  insanity  presents  a  clinical  history  and  symptoms, 
both  mental  and  physical,  pecnliar  to  it,  just  as  typhoid  fever 
or  any  other  disease  does.  Careful  and  repeated  observation 
will  usually  enable  the  examiner  to  detect  flaws  in  the  simu- 
lated insanity.  Thus,  a  patient  who  exhibits  mental  symp- 
toms resembling  acute  mania,  but  who  does  not  lose  weight  or 
sleeps  long  periods  spontaneously,  would  be  fraudulent. 

Or  it  would  be  equally  suspicious  if  the  mental  symptoms 
of  a  person  resemble  aggravated  melancholia,  while  food  is 
taken  or  the  temperature  is  normal,  and  the  circulation,  di- 
gestion, etc.,  are  good. 

A  study  of  the  mental  symptoms  may  also  be  heljiful. 
Thus,  for  instance,  systonintizcd  delusions  do  not  occur  in 
mania  or  non-systcniatizcd  ones  in  paranoia.  Simulators 
28— N.  D. 


434  MENTAL  DISEASES. 

usually  exaggerate  their  symptoms,  and  hence  frequently 
feign  mental  disturbances  not  belonging  to  the  form  of  in- 
sanity simulated. 

In  all  cases  a  decision  should  only  be  reached  after  close 
study,  and,  if  necessary,  repeated  observation. 

In  this  connection,  it  is  well  to  know  that  convicts  who 
most  of  the  time  are  well  behaved  may  have  sudden  attacks, 
in  which  they  are  destructive  and  noisy.  These  attacks  last 
a  few  days  and  then  pass  off  almost  as  suddenly  as  they 
came.  There  is  apparently  no  desire  to  feign,  and  the  sub- 
jects of  the  attack  will  tell  you  that  they  do  not  know  why 
they  did  it,  but  they  could  not  help  it.  Such  attacks  are 
familiar  to  all  who  are  associated  with  the  management  of 
prisons. 

IDIOCY. 

Classification  :  Idiocy  has  already  been  defined  on  page  395. 
In  degree,  these  cases  vary  from  children  who  are  feeble- 
minded or  backward  (in  other  words,  those  which,  while 
capable  of  mental  improvement  and  of  being  some  use  in  the 
world,  are  a  few  years  behind  their  age  in  mental  develop- 
ment) to  those  whose  minds  are  practically  blank.  It  must 
be  understood  that,  while  the  word  "  children  "  is  here  used, 
an  idiot  who  reaches  adult  age  is  still  an  idiot. 

An  adequate  classification  of  idiots  is  difficult  to  make. 
That  of  Peterson  is  as  follows  : 

1.  Hydrocephalic  idiocy ; 

2.  Microcephalic  idiocy  ; 

3.  Paralytic  idiocy  ; 

4.  Epileptic  idiocy  ; 

5.  Traumatic  idiocy  ; 

6.  Sensorial  idiocy  ; 

7.  Meningitic  idiocy  ; 

8.  Myxosdematous  idiocy,  or  cretinism  ; 

9.  Amaurotic  idiocy ; 

10.  Idiot  savants. 

IIydroce])halic,  microcephalic,  epileptic,  traumatic,  and 
meningitic  idiocy  are  readily  recognized  by  their  symptoms 
and   history,  as    is    also  the   paralytic  variety,  which  is  the 


IDIOCY.  435 

mental  enfeeblement  due  to  the  lesions  that  also  cause  the 
so-called  cerebral  palsies  of  children.  Amaurotic  idiocy  and 
cretinism  have  already  been  described  (see  pp.  388-393). 

The  term  idiot  savants  has  been  applied  to  all  idiots  or  im- 
beciles, from  whatever  cause,  that  exhibit  special  aptitudes  of 
one  kind  or  another,  as  in  music,  calculating,  memorizing, 
special  subjects,  etc. 

Sensorial  idiocy  is  a  form  due  to  a  congenital  or  early  loss 
of  two  senses,  as  sight  and  hearing.  Such  may  be  educated 
to  a  high  degree  of  mental  development. 

Space  will  not  permit  of  a  detailed  description  of  all  of 
these  forms,  and  only  the  general  points  will  be  here  described. 

Some  idiots  have  physiognomies  resembling  those  of  the 
lower  races  of  man.  These  are  often  spoken  of  as  mongolian, 
negroid  idiots,  etc. 

Idiocy — etiology :  Peterson  classifies  the  causes  of  idiocy  as 
follows  : 

r  Hereditary  transformation  of  nervous  and  mental  diseases. 
I   Pathological  heredity  in   the  form  of  vitiating  diseases  or  habits 
Degenerative.  -J       (tuberculosis,  rheumatism,  gout,  syphilis,  alcoholism,  etc.). 

I   Sociological  factors    (extreme    youth   of  parents,  extreme  age  of 

t      parents,  disproportionate  age  of  parents,  consanguinity). 

r  r  Maternal     '  Trauma,  shock,  fright,  diseases,  mater- 

I       aiKiLMi.    ^      nal  impressions. 
Gestational.      -J   p^joi  j :„    (  Syphilis,  heart  disease,  arteritis,  mor- 

I       orders  "  1      ^^^  processes  in  the  brain  and  men- 

L  ■     (      inges,  twin  pregnancy. 

Adventitious,  -j  (  Difficult   labor,    primogeniture,    premature   birth, 

I   Parturitional.  <      asphyxia  at  birth,  instrumental  injuries,  pressure 

(     on  the  cord. 

(  Convulsions,  cerebral  diseases,  trauma  to  the  head, 
I  Postnatal.  <  febrile  diseases,  mental  shock,  sunstroke,  over- 
L  (      pressure  at  school. 

Idiocy — symptoms :  Idiotic  or  imbecile  children  often  de- 
velop, physically  as  well  as  mentally,  more  slowly  than  do 
normal  children,  and  frequently  the  complaint  of  parents 
when  they  bring  these  children  to  the  physician  is  that,  while 
of  the  proper  age,  it  has  not  learned  to  walk  or  is  unable  to 
sit  up  without  support.  Of  course,  in  cases  of  paralytic 
idiocy  this  might  be  due  to  the  paralysis ;  in  the  class  of  cases 
referred  to,  no  evidence  or  history  of  paralysis  can  be  found. 
Further  examination  will  then  usually  elicit  the  facts  that 
teething  did  not  begin  as  soon  as  it  should,  and  that  its  prog- 
ress has  not  been  normal,  and  that  the  child  is  small  for  its 
age.      While  this  is  a  usual   history,  there  are  instances  in 


436  MENTAL  DISEASES. 

which  the  physical  development  is  as  good,  and  sometimes 
better,  than  in  normal  children  ;  and  the  failure  of  the  child 
to  develop  mentally  as  it  should  first  calls  attention  to  it. 
Mentally  it  does  not  act  as  other  children.  Often  such  chil- 
dren are  irritable  and  bad-tempered ;  they  do  not  notice 
objects  or  people ;  attention  cannot  be  attracted  ;  and  they 
do  not  show  other  well-known  evidences  of  awakening  intel- 
ligence. If  the  child  is  older,  it  will  be  found  that  it  has 
either  not  learned  to  talk  at  all  or  has  been  slow  in  doing 
so  ;  that  it  will  not  feed  itself,  and  that  it  continues  to 
soil  itself  as  infants  do.  Some  of  the  stigmata  of  degene- 
ration (see  p.  396)  will  be  found,  especially  the  high  V-shaped 
hard  palate. 

After  learning  to  walk,  great  restlessness  and  muscular 
activity  are  shown  by  many  of  these  cases.  They  continu- 
ally want  to  be  on  the  go ;  are  irritable,  mischievous,  and 
impatient  of  restraint.  Others  are  quiet ;  will  stay  in  one 
place  for  a  long  time  playing  with  some  trifling  objects. 

They  may  be  destructive,  cruel,  and  have  homicidal  in- 
stincts. Various  forms  of  sexual  perversion  and  masturba- 
tion may  be  present.  Some  cases  have  a  tendency  to  steal, 
and  show  great  cunning  in  securing  coveted  objects.  When 
sent  to  school  they  learn  slowly,  if  at  all,  and  are  several 
grades  behind  children  of  their  own  age. 

Of  course,  all  idiots  do  not  present  all  of  the  symptoms 
mentioned  above.  There  are  various  grades  of  intelligence 
and  tractability,  which,  however,  are  not  always  synchronous. 
A  child  may  be  quiet  and  well-behaved  ;  but  is  not  able  to 
learn  satisfactorily.  Others  may  learn  fairly  well  when  they 
try ;  but  are  mischievous,  irritable,  or  possibly  criminal  in 
their  instincts.  Others  again  may  be  especially  bright  in 
some  one  direction  (^idiot  savant).  Idiots,  especially  those 
that  do  not  learn  to  talk,  sometimes  emit  peculiar  sounds. 
Peculiar  muscular  movements  often  occur,  as  rhythmic  move- 
ments of  the  limbs,  rotary  movements,  etc.  These  are  inde- 
pendent of  the  various  post-hemiplegic  movements  (athetosis, 
choreiform  movements,  etc.)  which  may  occur  in  cases  of  para- 
lytic idiocy. 

Diagnosis  :  The  diagnosis  is  based  on  the  fact  that  the  child, 
either  from  birth  does  not  or  at  some  period  during  the  devel- 


IDIOCY. 


437 


opmental  period  ceases  to  progress  mentally  and  ethically  as 
it  shonld.  Tlie  type  of  the  condition  would  be  determined 
by  the  history  and  examination  of  the  case.  Thus  the  ex- 
tremely small  head  would  denote  the  microcejihalic  form  ;  the 
develo]inient  of  the  condition  after  the  onset  of  cerebral  \yay- 
alysis  the  paralytic  form,  etc. 

It  must  not  be  forgotten  that  idiots  may  sometimes  develop 
some  form  of  insanity,  and  also  that  they  are  often  given  to 
violent,  almost  maniacal  outbursts  of  temper,  which  must  not 
be  confounded  with  true  mania. 

Prognosis :  Of  course,  these  cases  cannot  be  cured  ;  but  by 
proper  means  of  education  many  of  them  can  be  made  fairly 
useful  members  of  society. 

The  only  treatment  is  the  sending  of  the  child  to  an  insti- 
tution devoted  to  the  education  of  such  children  ;  but  if  of 
such  a  type  that  nothing  can  be  done  there  for  him,  committal 
to  an  asylum  should  be  advised. 

Accompanying  conditions,  as  epilepsy  or  paralysis,  should 
be  treated  as  elsewhere  advised. 


/2f~-.  ^-^  >.^-^<^^ 


^yj2L&  <~' 


^^Zt^ 


^/^ 


INDEX. 


A. 

Accommodation  reflexes,  53 
Achromatopsia,  354 
Acromegaly,  383 

etiology,  383 

symptoms,  383-385 

treatment,  386 
Addison's  keloid,  381 
Adiposis  dolorosa,  392,  393 
Agarophobia,  343 
Ageusia,  138 
Agraphia,  242 
Alcoholic  meningitis,  185 

multiple  neuritis,  99,  100 
Alexia,  242 
Amaurosis,  48,  108 

hysterical,  108 

toxic,  108 
Amblyopia,  tobacco-,  108 
Amimia,  243 
Amusia,  243 

Amyotrophic  lateral  sclerosis,  222 
diagnosis,  224 
morbid  anatomy,  224 
symptoms,  lower  neuron,  222 

upper  neuron,  223 
treatment,  225 
Ansesthesia,  43 

areas  of,  287-291 

complete  transverse  lesions,  291 

hemi-lesions,  293 

of  hysteria,  351 

of  median  nerve,  156 

of  musculo-spiral  nerve,  155 

of  peroneal  nerve,  166 

of  plantar  nerves,  166 

of  popliteal  nerve,  166 

of  sciatic  nerve,  165 

of  small  sciatic  nerve,  165 

test  for,  45 

of  ulnar  nerve,  158 
Analgesia,  44 

test  for,  45 
Angio-neurotic  oedema,  378 


Anorexia  nervosa,  361 
Anosmia,  106 
Aphasia,  242-247 

auditory,  242,  244,  246 
cortical,  244 
subcortical,  246 
definition,  242 
diagnosis,  246 
genesis  of  speech,  243 
location  of  centres,  243 
motor,  242,  246 
cortical,  246 
subcortical,  246 
motor  and  sensory,  246 
varieties,  242 

auditory,  242,  244,  246 
conduction,  243 
cortical,  243 
motor,  242,  246 
sensory,  242 
subcortical,  243 
visaal,  242,  246 
visual,  242,  246 
cortical,  246 
subcortical,  246 
Aphemia,  242 
Ajjoplexy,  254 

ingravescent,  257 
Apraxia,  242 

Argyll-Eobertson  pupil,  53,  116 
Arms,  paralysis  of,  42 
Arsenical  multiple  neuritis,  101 
Association-centres,  23 

-tracts,  23 
Ataxia  (see  Incoordination),  46-48 
definition,  46 
dynamic,  47 
Friedreich's,  227 
hereditaiy,  227 

cerebellar,  229 
locomotor   (see    Locomotor    ataxia), 

190-197 
static,  47 
Athetosis,  35 

439 


440 


INDEX. 


Atrophy,  42 
muscular    (see    Muscular    atrophy), 
216-225 
Auditory  nerve  (see  Nerves),  136 
Axon,  19 

B. 

Battery,  58 
Beri-beri,  102 
Brachial  neuralgia,  162 
Brain,  abscess,  266 
diagnosis,  268 
etiology,  266 
symptoms,  267 
chronic,  267 
treatment,  269 
acute  softening  of,  262-264 
blood-supply,  247-251 
inflammation  of  (see   Encephalitis), 

265 
organic   disease  of,   as   a  cause   of 

headache,  79 
softening  of,  419 
tumors,  269 
diagnosis,  280 
etiology,  269 
symptoms,  270 
eye,  272 
focal,  273-279 
general,  271 
treatment,  281 
varieties,  269 
Brown-Sequard  paralysis,  293 
Bulbar  palsy,  210 
acute,  210 

polio-encephalitis  inferior,  211 

superior,  119 
symptoms,  211 
treatment,  211 
asthenia,  214 
etiology,  214 
symptoms,  214 
treatment,  215 
chronic  progressive,  211 
diagnosis,  212 
morbid  anatomy,  212 
symptoms,  211 
treatment,  214 

c. 

Caisson  disease,  295 

Caries  as  a  cause  of  headache,  79 

Cataphoresis,  59,  71,  129 

Cauda  equina,  lesions  of,  304 

Causalgia,  43 

Cerebellar  incoordination,  47 


Cerebral  hemorrhage,  254 
diagnosis,  259 
coma,  260 
alcoholic,  260 
diabetic,  260 
urajmic,  260 
treatment,  261 
incoordination,  47 
localization,  232-242 

central  convolutions,  234 
lesions  of,  236,  237 
destructive,  236 
irritative,  237 
muscle-sense,  236 
sensory  impressions,  235 
tactile-sense,  236 
voluntary    motor    impulses, 
235 
arm,  235 
face,  235 
larynx,  235 
leg,  235 
pharynx,  235 
tongue,  235 
trunk,  235 
centrum  ovale,  237 
cerebellum,  239 
corpora  quadrigemina,  239 
corpus  callosum,  237 
crus,  238 

internal  capsule,  237 
medulla,  241 
occipital  lobe,  242 
optic  thalamus,  238 
pons,  239 

prefrontal  region,  234 
Cervico-brachial  neuralgia,  162 
Charcot's  joints,  194 
Choked  disk,  109 
Chorea,  325-331 
adult,  329 

chronic  progressive,  330 
habit-,  329 
hereditary,  330 
definition,  330 
morbid  anatomy,  330 
symptoms,  330 
treatment,  331 
Huntington's,  330 
hysterical,  328 
insaniens,  328 
minor,  325 
paralytic,  327 
post-hcmiplegic,  36 
senile,  :«9 
Sydcnlianrs,  325 
"definition,  325 
diagnosis,  328 


INDEX. 


441 


Chorea,  Sydenham's,  etiology,  326 
morbid  anatomy,  328 
symptoms,  326 

chorea  insaniens,  328 
paralytic  chorea,  327 
treatment,  329 
Choreic  movements,  38 
Choreiform  affections,  325-333 
Circulatory  disturbances  as  a  cause  of 

headache,  78 
Claustrophobia,  343 
Coma,  34 

Compression-palsy,  93 
Contractions,  35,  60 
Contracture,  35 

of  hysteria,  359 
Conus  medullaris,  lesions  of,  304 
Convulsions,  34 
Convulsive  tremor,  332 
Cramp,  writers'  (see    Writers'   cramp), 

367,  368 
Cretinism,  391,  392 
Crossed  paralysis,  40 

D. 

Degenerating  muscle,  60 
Degeneration,  396 
complete,  61 
examination  for,  62 
partial,  62 
reaction  of,  61 
stigmata,  396 
Degenerations,  31,  32 
Delirium,  401 
Delusions,  399 
expansive,  399 
hypochondriacal,  399 
insane,  399 
non-systematized,  400 
of  persecution,  400 
systematized.  400 
Dementia,  413-424 
definition,  413 
etiology,  414 
paretic,  419 
diagnosis,  422 

cerebral  syphilis,  423 
chronic  alcoholism,  422 
neurasthenia,  422 
secondary  paranoia,  424 
treatment,  424 
symptoms,  419 
physical,  420 
primary,  416 
secondary,  414 
senile,  415 
terminal,  414 


Dementia,  varieties,  414 
Dendrites,  19 
Dendraxons,  20 
Deviation,  conjugate,  118,  122 
Diagnosis  of  acute  anterior  poliomv- 
elitis,  209 

myelitis,  299 

simple  cerebral  meningitis,  180 

spinal  leptomeningitis,  189 
of  alcoholic  meningitis,  186 
of  amyotrophic  lateral  sclerosis,  224 
of  aphasia,  246 

of  arthritic  muscular  atrophy,  217 
of  ataxic  paraplegia,  226 
of  brain-abscess,  268 

-tumors,  280 
of  cerebral  hemorrhage,  259 

palsies  of  children,  204 
of  chronic  cerebral  leptomeningitis, 
187 

myelitis,  302 

ophthalmoplegia,  120 

progressive  bulbar  palsy,  212 

spinal  leptomeningitis,  189 
of  diseases  of  tenth  cranial    nerve, 

142 
of   epidemic   cerebro-spinal  menin- 
gitis, 182 
of  epilepsy,  337-339 
of  facial  spasm,  135 
of  headache,  80 
of  hysteria,  362 
of  locomotor  ataxia,  195 
of  migraine,  83 
of  multiple  neuritis,  103 

sclerosis,  315 
of  neurasthenia,  345 
of  neuritis  of  sciatic  nerve,  170 
of  parsesthesia,  87 
of  paralysis  agitans,  325 

of  brachial  plexus,  161 

of  fifth  cranial  nerve,  126 

of  phrenic  nerve,  150 

of  spinal  accessory  nerve,  143 

of  twelfth  nerve,  147 
of  paretic  dementia,  422 
of  primary  brachial  neuritis,  159 

lateral  sclerosis,  199 
of    progressive    neurotic    muscular 

atrophy,  218 
of  serous  meningitis,  185 
of  softening  of  brain,  264 
of  spasm    of    muscles   supplied    by 

spinal  accessory  nerve,  145 
of  spastic  paralysis,  hereditary,  206 
of  Sydenham's  chorea,  328 
of  syphilis  of  nervous  system,  320 
of  syringomyelia,  312 


442 


INDEX. 


Diagnosis  of  vertigo,  90 
Diphtheritic  multiple  neuritis,  101 
Diplegia,  40 

spastic  (see  Paraplegia,  spastic),  201 
Diplopia,  117 

Diichenue,  infantile  progressive  mus- 
cular atrophy,  219,  221 
Dynamic  ataxia,  47 
Dyschromatopsia,  354 
Dystrophies,  219 

E. 

Electric  irritability,  60 
decreased,  61 
simple  increased,  60 
Electricity,  56-72 
application  of,  63 

diagnosis  and  prognosis,  60-63 
AnClC,  62 
AnOC,  62 
CaClC,  62 
CaOC,  62 
electric  apparatus,  57 
faradic,  57,  58 
galvanic,  57 
static,  57 
faradic,  58,  62,  65 
galvanic,  57,  62,  71 
physics,  56-59 
ampere,  57 
conductors,  56 
insulators,  57 
milliampere,  57 
negative  electricity,  56 
ohm,  56 

positive  electricity,  56 
potential,  56 
volt,  56 
physiology  of,  59 
static,  57,  63 
therapeutics  of,  63-72 
cataphoresis,  71 
muscle  stimulant,  64,  65 
psychic  effects,  64 
sedative,  71 
skin,  63,  66 
tonic,  63,  68 
Electrolysis,  59 
Electrotonos,  60 
Emotional  enfeeblement,  398 
Emprosthotonos,  370 
Encephalitis,  265-269 
acute  hemorrhagic,  266 
acute  suppurative   (see    Brain,   ab- 
scess of ),  266 
Endemic  multiple  neuritis,  102 
symptoms  of,  103 


Epilepsy,  333-340 
definition,  333 
diagnosis,  337,  339 

from  hysteria,  338 
etiology,  333,  334 
Jackson  iau,  333,  337 
morbid  anatomy,  337 
symptoms,  334,  337 
grand  mal,  334 

the  attack,  335 
epileptic  automatism,  336 
precursory  symptoms,  334 
status  epilepticus,  336 
transient  paralysis,  336 
Jacksonian  epilepsy,  337 
petit  mal,  336 
fainting,  336 
giddiness,  336 
jerks,  336 
mental  state,  336 
sensations,  cardiac,  337 
epigastric,  337 
hands,  337 
head,  337 
olfactory,  337 
peripheral,  337 
throat,  337 
visual,  336 
treatment,  339,340 
Erb's  type  of  muscular  dystrophy,  219, 

221 
Erotomania,  401 
Erythromelalgia,  171 
definition,  171 
etiology,  171 
symptoms,  171 
treatment,  171 
Exaltation,  397 
Exophthalmic  goitre,  388 


F. 

Face,  paralysis  of,  41 
Facial  hemiatrophy,  379 
hemihypertrophy,  381 
Friedreich's  disease,  227 

G. 

Genital  function,  reflexes,  54 

Gilles  de  la  Tourette's  disease,  331 

Girdle  pain,  42 

Gliosis,  31 

Globus  hystericus,  348 

Glossopharyngeal  nerve  (see  Nerves), 

137 
Goitre,  exophthalmic,  388 


INDEX. 


443 


H. 

Hsematoma  auris,  397 
Hajniatomyelia,  294 
Hiematorrhachis,  293 
Hallucination,  399 
Headache,  78-81 
causes,  78 
caa-ies,  79 

circulatory  disturbances,  78 
neuroses,  79 

organic  disease  of  brain,  79 
reflex  irritation,  78 
toxsemic,  78 
diagnosis,  80 
pathology,  79 
sick,  82 
symptoms,  80 
treatment,  81 
Hearing,  examination  of,  49 
Hebephrenia,  429 
Hemiansesthesia,  43 
Hemianopsia,  48,  110 
binasal,  112 
bitemporal,  112 
homouymous,  112 
left,  112 
right,  112 
horizontal,  110 
vertical,  110 
Hemiatrophy,  progressive  facial,  379- 

381 
Hemicrania,  82 
Hemiplegia,  40 
spastic,  200 
etiology,  200 
symptoms,  200 
treatment,  205 
Hemorrhage,  cerebral,  254 
into  cerebellum,  257 
into  cord,  294 
into  pons,  257 
meningeal,  251 
spontaneous,  251 
traumatic,  252 
spinal  meningeal,  293 
subdural,  252 
supradural,  254 
Hereditary  ataxia,  227 
cerebellar,  229 
Friedrich's  disease,  227 
Herpes  zoster,  163 
Huntington's  chorea,  330 
Hydrocephalus,  183,  187 
acute  (see  Meningitis,  tubercular),  183 
chronic,  187 
definition,  187 
symptoms,  188 


Hydrocephalus,  chronic,  treatmeut,188 
Hydrophobia,  371 
etiology,  371 
pseudo-,  372 
symptoms,  371 
treatment,  372 
Hydrotherapeutics,  74-76 
as  a  sedative,  75 
drip-sheet,  75 
hot  sitz-baths,  75 
lukewarm  baths,  75 
wet-pack,  75 
as  a  tonic,  74 
cold  plunges,  75 
douches,  75 
shower-baths,  75 
Hyperaesthesia,  42 
of  hysteria,  355 
retinal,  109 
Hypergeusia,  138 
Hyperosmia,  106 

Hypertrophy,  pseudo-muscular,  219 
Hypoglossal  nerve  (see  Nerves),  146 
Hysteria,  347-363 
definition,  347 
diagnosis,  362 
etiology,  347 
major,  350 
minor,  350 
pathology.  362 
symptoms,  348-362 

interparoxysmal,  350-362 
sensory,  351-358 
anaesthesia,  351-355 
achromatopsia,  354 
blindness,  353 
central  scotomata,  353 
dyschromatopsia,  354 
all  forms,  353 
hemi-,  351 
hemianopsia,  353 
in  patches,  352 
of  smell,  355 
of  taste,  355 
hyperaesthesia,  355 
paresthesia,  358 
motor,  358-361 
contracture,  359 
incoordination,  361 
paralysis,  358 
diplegia,  358 
hemiplegia,  358 
monoplegia,  358,  359 
paraplegia,  359 
tremor,  361 
paroxysmal,  348-350 
the  paroxysm,  348 
globus  hystericus,  348 


444 


INDEX. 


Hysteria,  symptoms,  paroxysmal,  typ- 
ical convulsion,  348,  349 
catalepsy,  350 
hysteria  major,  350 
minor,  350 

hysterical  somnambulism,  350 
lethargy,  350 
trance,  350 
psychical,  362 
visceral,  361 
treatment,  363 
Hysterical  amaurosis,  188 
Hystero-epilepsy,  348 


I. 


Idiocy,  434-437 

classification,  434 

definition,  395 

etiology,  435 

sensorial,  435        v 

symptoms,  435 

treatment,  437 
Idiopathic  multiple  neuritis,  99 

reflexes,  54 
Idiot  savants,  435,  436 
Illusion,  399 

Imperative  conceptions,   400 
Incoordination  (see  Ataxia),  46-48 

cerebellar,  47 

cerebral,  47 

examination,  47,  48 
Romberg  sign,  47 

of  hysteria,  361 

peripheral  nerves,  47 

spinal  cord,  47 
Induction,  58 
Inflammation,  31 

cause,  31 

form,  31 

of  nerves  (see  Neuritis),  94 
Insanity,  395,  397-434 

alcoholic,  426 
acute,  426 
chronic,  427 

classification,  401,  402 

confusional,  416-419 

definitions,  395 

epileptic,  425 
acute,  425 
chronic,  426 
psychic,  426 
varieties,  425 

examination  of  the  insane,  432 

feigned,  433 

forms,  397 

hysterical,  428 

masturbational,  429 


Insanity,  periodic  or  recurrent,  410 

of  pubescence,  429 

puerijeral,  430 

stuporous,  416-419 
Insomnia,  91 

etiology,  91 

symptomat(jlogy,  91 

treatment,  91 
Intellectual  function,  398 
diminished,  398 
increased,  398 
Intercostal  neuralgia,  162 
Interstitial  neuritis,  94 
Iridoplegia,  116 

reflex, 116 

total,  116 
Iris,  paralysis  of,  41 

J. 

Jacksonian  epilepsy,  227,  333,  337 

K. 

Kak-ke,  102 
Katatonia,  431 
Kernig's  symptom,  178 
Kleptomania,  400 

I.. 

Landouzy-Dejerine  type  of  muscular 

dystrophy,  219,  221 
Landry's  disease,  215 
Larynx,  anaesthesia  of,  141 

paralysis  of  (see  Paralysis),  140 
spasm  of  (see  Spasm),  141 
Leg,  paralysis  of,  42 
Leontiasis  ossea,  387 
Leptomeningitis,  178-189 
chronic  cerebral,  187 
diagnosis,  187 
symptoms,  187 
treatment,  187 
spinal,  188 
acute,  188 

diagnosis,  189 
symptoms,  189 
treatment,  189 
chronic,  188 
diagnosis,  189 
symptoms,  189 
treatment,  189 
varieties  (see  Meningitis),  178 
epidemic  cerebro-spinal,  181 
serous,  184 
simple,  178 
syphilitic,  187 
tubercular,  181 


INDEX. 


445 


Light-reflexes,  53 
Little's  disease,  201 
Loealizatiou,    cerebral     {see     Cerebral 
localisation),  232-242 
spinal  (see  Spinal  localization),  283- 
293 
Lockjaw  (see  Tetanus),  369 
Locomotor  ataxia,  190-197 
definition,  190 
diagnosis,  195 

ataxic  paraplegia,  195 
cerebellar  disease,  195 
general  paresis,  196 
multiple  neuritis,  195 
myelitis,  195 
etiology,  190 
morbid  anatomy,  191 
prognosis,  196 
symptoms,  192 
ataxic  stage,  193 
ansesthesia,  194 
Charcot's  joints,  194 
herpes,  194 

mental  symptoms,  194 
parsesthesia,  194 
perforating  ulcer,  194 
Romberg  symptom,  193 
incipient  stage,  192 
"crises,"  192 
loss  of  knee-jerk,  193 
ocular  symptoms,  193 
trophic  disturbances,  193 
paralytic  stage,  195 
treatment,  196 
abstinence,  196 
from  alcohol,  196 
from  sexual  indulgence,  196 
from  tobacco,  196 
antisyphilitic,  196 
arsenic,  196 

bichloride  of  gold  and  sodium,  196 
couuterirritation,  197 
electricity,  197 
hydrotherapy,  197 
muscle  re-educatiou,  197 
nitrate  of  silver,  196 
nitroglycerin,  197 
rest-cure,  197 
strychnine,  196 
suspension,  197 
Lumbar  plexus,  neuralgia  of,  172 
paralysis  of,  163 

M. 

Mai,  grand,  333,  334 

petit,  333,  336 
Maniniary  neuralgia,  163 


Mania,  406-409 
of  doubt,  343 
hypo-,  407 
symptoms,  406 
acute,  407 
acute  delirious,  408 
chronic,  408 
hyperacute,  408 
subacute,  407 
treatment,  409 
Massage,  72 
efflurage,  72 
a  friction,  72 
petrissage,  72 
tapotement,  72 
Mastodynia,  163 
Megrim,  82 
Melancholia,  402 
agitata,  403 
attonita,  404 
simple,  403 
treatment,  405 
with  delusions,  403 
Memory,  impairment  of,  398 
kinsesthetic,  244 
visual,  244 
Meniere's  disease,  89 
acute,  90 
chronic,  89 
treatment,  90 
Meningeal  hemorrhage,  251-254 
spontaneous,  251 
subdural,  252 
traumatic,  252 
Meninges,  inflammation  of,  173-189 
Meningitis,  178-189 

acute  simple  cerebral,  178 
diagnosis,  180 
morbid  anatomy,  180 
symptoms,  179 

Kernig's  symptom,  179 
treatment,  181 
alcoholic,  185 
diagnosis,  186 
etiology,  185 
morbid  anatomy,  186 
symptoms,  186 
treatment,  186 
chronic  (see  Leptomeningitis),  187 
epidemic  cerebro-spinal,  181 
diagnosis,  182 

lumbar  puncture,  182 
etiology,  181 
symptoms,  182 
treatment,  183 
serous,  184 
diagnosis,  185 
etiology,  184 


446 


INDEX. 


Meningitis,  serous,  symptoms,  184 
treatment,  185 
tubercular,  183 
etiology,  183 
morbid  anatomy,  184 
symptoms,  183 
treatment,  184 
Migraine,  81-85 
diagnosis,  82 
etiology,  82 
pathology,  83 
symptoms,  82 
briglit  spot,  82 
hemianopsia,  83 
synonyms,  82 
treatment,  84 
for  the  attack,  84 
for  the  disease,  84 
Mind-blindness,  242 
Monomania  (see  Paranoia),  410 
Monophobia,  343 
Monoplegia,  40 
Morbid  desires,  401 

impulses,  400 
Morphcea,  381 
Morton's  disease,  172 
Morvan's  disease,  311 
Motor  tracts,  24 
Movements,  38,  39 
associated,  39 
athetoid,  36 
choreic,  38 
forced,  39 
Muscle-reflexes,  51 
-sense,  45 
loss  of,  46 
Muscular  atrophy,  216-225 
arthritic,  216 
definition,  216 
diagnosis,  217 
etiology,  216 
pathology,  217 
symptoms,  216 
treatment,  217 
muscular  dystrophies  (see  Muscu- 
lar dystrophies),  219 
progressive    (see   Amyotrophic  lat- 
eral sclerosis),  222 
progressive  neurotic,  217 
diagnosis,  218 
etiology,  217 
morbid  anatomy,  218 
symptoms,  218 
treatment,  219 
dystropliies,  219 

morbid  anatomy,  221 
treatment,  222 
types,  219 


Muscular    dystrophies,    types,    facio- 
scapulo-humeral,  221 
pseudo-muscular    hypertrophy, 

219 
scapulo-humeral,  221 
movements,  72-74 

body  and  lower  limbs,  73 
hands  and  arms,  72 
Myelitis,  296-304 
acute,  296 

diagnosis,  299 
softening,  297 
red,  297 
yellow,  297 
symptoms,  297-299 
acute  transverse  myelitis,  297 
cervical,  299 
dorsal,  299 
lumbar,  299 
treatment,  301 
chronic,  301 
diagnosis,  302 
etiology,  301 
symptoms,  301 
treatment,  303 
compression,  303 
symptoms,  303 
treatment,  304 
Myoclonus  multiplex,  332 
Myospasm,  332 
Myotonia  congenita,  375 
Myotonic  reaction,  62 
Myscedema,  389 
symptoms,  390 
treatment,  390 

N. 

Nerves,  chorda  tympani,  131 

cranial,    diseases   of    (see    Olfactory 
nerves  ;  Optic  nerve  ;  Nerves,  third, 
etc.),  106-148 
eighth  cranial,  136 
irritation,  136 
paralysis.     (See  Paralysis.) 
eleventh  cranial  or  spinal  accessory, 
142 
anatomy,  142 
paralysis.     (See  Paralysis.) 
spasm.     {See  Spasm.) 
facial,   130-136  , 

anatomy,  130 

chorda  tympani,  131 
paralysis   of  (see  Paralysis),  131- 

134" 
siKism  of  muscles  (see  Spasm),  134 
fifth  cranial,  12.3-130 
anatomy,  123 


INDEX. 


U1 


Nerves,    fifth    cranial,   neuralgia    of. 
(See  Neuralgia.) 
paralysis  of.     (See  Paralysis.) 
fourth  cranial,  117 

anatomy,  117 
median,  anaesthesia  of,  156 

paralysis  of,  156 
musculo-cutaneous,  paralysis  of,  154 
niusculo-spiral,  ansesthesia  of,  155 

paralysis  of,  154 

ninth  cranial  or  glosso-pharyngeal, 

137, 138 

anatomy,  137 

diseases,  137 

olfactory,  106 

disturbance  of  function,  106 
peripheral,    diseases    of    (see    Palsy 

and  Neuritis),  93-105 
peroneal,  anaesthesia  of,  166 
phrenic,  149-150 
paralysis,  149 
plantar,  anaesthesia  of,  166 
popliteal,  anaesthesia  of,  166 
sciatic,  anaesthesia  of,  165 

small,  anaesthesia  of,  165 
seventh  cranial,  130-136 
sixth  cranial,  117 
anatomy,  117 

paralysis      of     muscles.       (See 
Paralysis.) 
spinal,    diseases    of    (see    Paralysis, 
Ansesthesia,    Neuralgia,    and    Neu- 
ritis), 149-172 
tenth    cranial,     pneumogastric    or 
vagus,  138-142 
anatomy,  138 
diseases  of,  139 
diagnosis,  142 
etiology,  139 
symptoms,  140 
treatment,  142 
paralysis  of.     (See  Paralysis.) 
spasm  of.     (See  Spasm.) 
third  cranial,  114 
anatomy,  114 

paralysis      of      muscles.      (See 
Paralysis.) 
twelfth  or  hypoglossal,  146 
anatomy,  146 
paralysis.     (See  Paralysis.) 
ulnar,  anaesthesia  of,  158 
paralysis  of,  156 
Nervous  system,  syphilis  of,  316-322 
Neuralgia,  85,  86 
brachial,  162 
etiology,  162 
symptoms,   162 
treatment,  162 


Neuralgia,  cervico-brachial,  162 
cervico-occipital,  149 
etiology,  149 
symptoms,  149 
treatment,  149 
etiology,  85 

of  fifth  cranial  nerve,  127 
symptoms,  127, 128 

brow-ague,  127 
treatment,  128-130 
aconitia,  129 
dry  heat,  129 
electricity,  129 
nitroglycerin,  129 
resection,  130 
salicylates,  129 
forms,  85 

"hallucinatory,"  85 
intercostal,  162 
etiology,  162 
symptoms,  162 
treatment,  163 
of  lumbar  plexus,  172 
mammary,  163 
metatarsal,  172 
"reminiscent,"  85 
symptoms,  85 
treatment,  86 
Neurasthenia,  340-347 
definition,  340 
diagnosis,  345 
etiology,  341 
pathology,  345 
symptoms,  341-345 
motor,  341 

knee-jerks,  342 
tremor,  341 
weakness,  341 
psychic,  343 
fear,  343 

introspection,  343 
memory,  343 
sensory,  342 
backache,  342 
headache,  342 
malaise,  342 
special  senses,  342 
vertigo,  342 
somatic,  343 
circulatory,  344 
digestive,  343 
secretory,  344 
sexual,  344 
treatment,  346 
douches,  346 
out-door  life,  346 
re.st-treatment,  346 
Neuritis,  94-105 


448 


INDEX. 


Neuritis,  acute,  94,  96 
ascending,  96 
chronic,  96 
interstitial,  94 
localized,  95 
diagnosis,  96 
duration,  96 
etiology,  95 
symptoms,  95 
treatment,  97 
morbid  auatomv,  94 
multiple,  98-105 
alcoholic,  99,  100 
arsenical,  101 
diagnosis,  103 

from  acute  myelitis,  104 
from  acute  poliomyelitis,  103 
from  diphtheritic  neuritis,  104 
from  locomotor  ataxia,  104 
diphtheritic,  101 
endemic,  102 

symptoms,  103 
etiology,  98 
dyscrasia,  98 
idiopathic,  98 
poisons,  98 
from  within,  98 
from  without,  98 
idiopathic,  99 
from  lead,  101 
morbid  anatomy,  98 
prognosis,  105 
recurrent,  99 
symptoms,  98 
treatment,  105 
optic  (see  Optic  neuritis),  109 
parenchymatous,  94,  95 
of  plantar  nerves,  166 
primary  brachial,  159 
diagnosis,  159 
etiology,  159 
radicular,  159 
symptoms,  159 
treatment,  160 
sciatic  nerve,  168 
diagnosis,  170 
etiology,  168 
morbid  anatomy,  168 
symptoms,  169 
treatment,  170 
Neuron,  19 

constituents,  19 
axon, 19 
collaterals,  20 
cell-hody,  19 
dendrites,  19 
dendraxons,  20 
end-brush,  20 


Neuron,  functions,  20 

eflerent  impulses,  20 

sensory  impressions,  21 
Neurons,  relations  to  each  other,  21 
Neuroses,  363-369 
as  a  cause  of  headache,  79 
occupation-,  367-369 

definition,  367 

etiology,  367 

symptoms,  367 

treatment,  369 

varieties,  368 
traumatic,  363-367 

etiology,  364 

symptoms,  364 

treatment,  364 
Neurosis,  33 
Numbness,  waking-,  86 
Nymphomania,  401 
Nystagmus,  122 

o. 

Ocular  paralysis,  119 
Oedema,  angio-neurotic,  378 
Olfactory  nerves,  106 

disturbance  of  function,  106 
tract,  106 
Ophthalmoplegia,  119-122 
acute,  119 
etiology,  119 
symptoms,  119 
treatment,  120 
chronic,  120 
diagnosis,  120 
etiology,  120 
symptoms,  120 
treatment,  121 
externa,  120 
Interna,  120 
Opisthotonos,  369 
Optic  atrophy,  110 
consecutive,  110 
etiology,  110 
primary,  110 
secondary,  110 
nerve,  diseases  of,  106-114 
disturbances  of  vision,  108 
visual  pathway,  106 
neuritis,  109, 110 
etiology,  109 
intra-ocular,  109 
orbital,  109 
papillitis,  109 
symptoms,  109 
treatment,  110 
tract,  diseases  of,  106-114 
Orthotonos,  369 


INDEX. 


449 


Osteo-arthropathy,  liypertrophit-  pul- 
monary, 38ti,  ;J87 

P. 

Pacbymouiugitis,  173 
external,  173, 174 
cerebral,  173 
spinal,  174 
internal,  175, 176 
cerebral,  175 
spinal,  176 
Pain,  42 

girdle,  42 
Palmus,  331 

Palsies,  cerebral,  of  cbildren,  200 
diagnosis,  204 
morbid  anatomy,  203,  204 
treatment,  205 
Palsy,  Bell's,  132 
birth-,  201 

bulbar  (see  Bulbar  palsy),  210 
compression-,  93 
pressure-,  93 
shaking,  323 
Parsesthesia,  43,  86 
aero-,  86 
diagnosis,  87 
etiology,  87 
of  hysteria,  358 
meralgia,  86 
pathology,  87 
symptoms,  87 

waking-numbness,  87 
treatment,  88 
Parageusia,  138 
Paralysis,  39 
acute  ascending,  215 

morbid  anatomy,  215 
symptoms,  215 
treatment,  216 
agitans,  323-325 
diagnosis,  325 
etiology,  323 
morbid  anatomy,  324 
symptoms,  323 
treatment,  325 
brachial,  160,  161 
lower-arm  type,  160 
upper-arm  type,  160 
Brown-Sequard,  293 
of  cardiac  branches  of  vagus,  141 
central,  40 

of  circumflex  nerve,  151 
etiology,  151 
symptoins,  151 
combined,  of  brachidi  i)lexus,  158 
diagnosis,  161 

29— N.  D. 


Paralysis,      combined,      of      brachial 
l)lexus,  etiology,  158 
symptoins,  158 
of  ocular  nuiscles,  119 
crossed,  40 
divers',  295 

of  eighth  cranial  nerve,  136 
aphasia,  13() 
etiology,  136 
vertigo,  136 
Er1)'s,  160 

of  facial  or  seventh  cranial  nerve, 
131-134 
central,  131 
etiology,  131 
peripheral,  131 
symptoms,  132 
bilateral,  133 
central,  132 
chronic,  132 
nuclear,  132 
peripheral,  133 
treatment,  134 
family  periodical,  374 
of  fifth  cranial  nerve,  127 
crossed,  126 
diagnosis,  126 
etiology,  123,  124 
symptoms,  124-126 
motor  portion,  126 
sensory  division,  124 
treatment,  126 
glosso-labio-laryngeal     (see    Bulbar 

palsy,  chronic  progressive),  211 
of  hysteria,  358 
infantile,  207 

of  infrascapular  nerve,  151 
etiology,     151 
symptoms,  151 
Klumpke's,  161 
of  larynx,  140 
abductor,  140, 141 
bilateral,  140, 141 
unilateral,  140, 141 
adductor,  140,141 
of  lumbar  plexus,  163 
etiology,  163 
symptoms,  164 
anterior  crural  nerve,  164 
obturator  nerve,  164 
of  median  nerve,  156 
etiology,  156 
symptoms,  156 
methods  of  examination,  40 
arms,  42 
face,  41 
iris,  41 
leg,  42  5 


450 


INDEX. 


Paralysis,   methods   of   examinatiou, 
soft  palate,  41 
tongue,  41 
of  muscles  supplied  by  fourth  crauial 

nerve,  117 
of  muscles  supplied  by  sixth  cranial 

nerve,  118,  119 
of  muscles  supplied  by  third  cranial 
nerve,  114-117 
etiology,  114 
of  muscles  supplied  by  third  cranial 
nerve, intro-ocular  mus  ■ 
cles,  116 
recurrent  form,  116 
pathology,  117 
single  muscles,  116 
symptoms,  115 
total,  115 
of  musculo-cutaneous,  nerve,  154 
etiology,  154 
symptoms,  154 
of  musculo-spiral  nerve,  154 
etiology,  154 
symptoms,  154 
ocular,  119 

chronic  nuclear,  120 
of  oesophageal  and  gastric  branches 

of  vagus,  141 
peripheral,  40 
of  pharynx,  140 
of  phrenic  nerve,  149 
diagnosis,  150 
etiology,  149 
symptoms,  149 
treatment,  150 
of  posterior  thoracic  nerve,  150 
etiology,  150 
symptoms,  151 
of  sacral  plexus,  165 
etiology,  165 
symptoms,  165 

peroneal  nerve,  165 
plantar  nerves,  166 
popliteal  nerve,  166 
sciatic  nerve,  165 
small  sciatic  nerve,  165 
spastic,  198 

hereditary,  205 
cerebral  type,  206 
diagnosis,  206 
morbid  anatomy,  206 
spinal  type,  205 
treatment,  206 
of  infants,  200 
of  spinal  accessory  nerve,  142 
diagnosis,  143 
etiology,  142 
symptoms,  143 


Paralysis  of  spinal  accessory  nerve, 
treatment,  143 
of  spinal  nerves,  treatment,  168 
of  twelfth  nerve,  147 
crossed,  147 
diagnosis,  147 
etiology,  147 
symptoms,  147 
treatment,  147 
of  ulnar  nerve,  156 
etiology,  156,  157 
symptoms,  156, 157 
Paramyoclonus  multiplex,  332 
Paranoia,  410-413 
diagnosis,  412 
symptoms,  411 
treatment,  413 
Paraphasia,  243 
Paraplegia,  40 
ataxic,  225 
diagnosis,  226 
etiology,  225 
morbid  anatomy,  226 
symptoms,  225 
treatment,  227 
spastic,  201 
etiology,  201 
symptoms,  202 
treatment,  205 
Parenchymatous  neuritis,  94,  95 
Paresis,  39 

Parkinson's  disease,  323 
Parosmia,  106 

Pathology     of     arthritic      muscular 
atrophy,  217 
of  headache,  79 
of  hysteria,  362 
of  migraine,  83 
of  neurasthenia,  345 
of  parsesthesia,  87 
of  syphilis  of  nervous  system,  317 
of  vertigo,  88 
Peripheral  nerves  incoordination,  47 
Pharynx,  paralysis  of,  140 

spasm  of,  140 
Pleurothotonos,  369 
Pneumogastric  nerve  (see  Nerves),  138 
Pole,  negative,  58 

positive,  58 
Polio-encephalitis  inferior,  131 
superior,  119 

of  Wernicke,  119 
Poliomyelitis,  anterior,  acute,  207 
diagnosis,  209 
etiology,  207 
morbid  anatomy,  208 
symptoms,  207 
treatment,  209 


INDEX. 


451 


Prefixes,  33 

Pressure-palsy,  93 
treatment,  94 

Prognosis  of  locomotor  ataxia,  196 
of  multiple  neuritis,  105 
of  syphilis  of  nervous  system,  321 

Prosopalgia,  127 

Psychosis,  33 

Ptosis,  115,  121 

Pyromania,  400 

R. 

Rabies  (see  Hydrophobia),  371 
Raynaud's  disease,  376 
symptoms,  376 
treatment,  378 
Reaction  of  degeneration,  61 
Recurrent  multiple  neuritis,  99 
Reflex  irritation  as  a  cause  of  head- 
ache, 78 
Reflexes,  49-54 

accommodation-,  53 
deep,  51 
defecation,  53 
genital  functions,  54 
idiopathic,  54 
light-,  53 
muscle-,  51 
reflex  action,  49 
skin-,  50,  51 
abdominal,  51 
cremasteric,  51 
epigastric,  51 
plantar,  51 
pupillary,  51 
tendon-,  51 

ankle-clonus,  52 
ankle-jerk,  52 
knee-jerk,  51 
muscle-jerk,  52 
wrist-jerk,  52 
urination,  53 
visceral,  53 
Rest-treatment,  76 
diet,  76 

schedule  of,  76 
electricity,  76 
isolation,  76 
massage,  76 
nurse,  76 
rest,  76 
Risus  sardonicus,  369 
Romberg  sign,  47 

S. 
Sacral  plexus,  paralysis  of,  1G5 
St.  Anthony's  dance,  325 


St.  Vitus's  dance,  325 
Saltatory  spasm,  332 
Satyriasis,  401 
Sciatica  (sec  Neuritis),  168 
Scleroderma,  381 
Scleroses,  31 

Sclerosis,    combined,    of  spinal   cord, 
230,  231 
lateral,      amyotrophic     (see    Amyo- 
trophic lateral  sclerosis),  222 
multiple,  313 
definition,  313 
diagnosis,  315 
etiology,  313 
pathology,  313 
symptoms,  314 
cardinal,  314 

disorders  of  speech,  315 
exaggerated  jerks,  315 
"  intention-tremor,"  314 
muscular  weakness,  314 
nystagmus,  315 
vertigo,  etc.,  315 
treatment,  316 
posterior  spinal,  190-197 
primary  lateral,  198 
diagnosis,  199 
etiology,  198 
morbid  anatomy,  199 
symptoms,  198 
treatment,  199 
Scotomata,  353 
Secretory  disturbances,  55 
Sensory  tracts,  27 
Serous  leptomeningitis,  184 

meningitis,  184 
Sick  headache,  82 
Sight,  examination  of,  48 
Skin -reflexes,  50,  51 
Smell,  examination  of,  49 
Softening  of  brain,  262 
diagnosis,  264 
etiology,  262 
symptoms,  262 
embolism,  262 
thrombosis,  263 
treatment,  264 
Soft  palate,  paralysis  of,  41 
Spasms,  35 
of     cardiac    branches     of     vagus, 

141 
facial,  134 
diagnosis,  135 
etiology,  134 
symptoms,  135 
treatment,  136 
of  larynx,  141 

laryngismus  stridulus,  141 


452 


INDEX. 


Spasms  of  muscles  supplied  by  spinal 
accessory  nerve,  143 
clonic,  145 

symptoms,  145 
diagnosis,  145 
tonic,  144 

symptoms,  144 
torticollis,  143 
treatment,  146 
wry-neck,  143 
of  ocular  muscles,  122 
clonic,  122 
tonic,  122 
of  oesophageal  and  gastric  branches 

of  vagus,  141 
of  pharynx,  140 
saltatory,  332 
Special  senses,  examination  of,  48,  49 
hearing,  49 
sight,  48 
smell,  49 
taste,  49 
Spinal  accessory  nerve  (see  Nerves),  142 
Spinal  cord,  compression  of,  303 
etiology  of,  303 
incoordination,  47 
inflammation   (see  Myelitis),  296- 

304 
tumors  of,  305-308 
extra-medullary,  305 
medullary,  305 
symptoms  of,  306 
treatment  of,  308 
varieties  of,  305 
localization,  283-293 
areas  of  ansesthesia,  287-291 
centres,  283 

reflex  and  vaso-motor,  283 
sensory  and  trophic,  283 
spinal  automatic,  283 
enlargements,  284 
segments,  283 
functions  of  each,  285-287 
Spotted  fever,  181 
Stereognostic  sense,  45 
Stigmata,  351,  396 
of  degeneration,  396 
anatomical,  396 
hiBmatoma  auris,  397 
mental,  397 
physiological,  397 
of  hysteria  (see  Hysteria),  351 
Strabismus,  122 
Stupor,  34 

Sydenham's  chorea,  325 
Symptoms  of  acromegaly,  383-385 
of  acute  anterior  poliomyelitis,  207 
ascending  paralysis,  215 


Svmptoms  of  acute  bulbar  palsy,  211 

myelitis,  297-299 

ophthalmoplegia,  119 

simple  cerebral  meningitis,  179 

spinal  meningitis,  189 
of  alcoholic  meningitis,  186 
of  amyotrophic  lateral  sclerosis,  222, 

223 
of  arthritic  muscular  atrophy,  216 
of  asthenic  bulbar  palsy,  214 
of  ataxic  paraplegia,  225 
of  brachial  neuralgia,  162 
of  brain-abscess,  267 

-tumors,  270 
of  cervico-occipital  neuralgia,  149 
of  chronic  cerebral  leptomeningitis, 

187 
of  hydrocephalus,  188 
of  myelitis,  301 
of  ophthalmoplegia,  120 
of  progressive  bulbar  palsy,  211 
of  spinal  leptomeningitis,  189 
of  compression-myelitis,  303 
of  diseases  of  tenth  cranial  nerve, 

140 
of  endemic  multiple  neuritis,  103 
of  epidemic  cerebro-spinal  menin- 
gitis, 182 
of  epilepsy,  334-337 
of  erythromelalgia,  171 
of  facial  spasm,  135 
of  headache,  80 
of  hereditary  chorea,  330 
of  hydrophobia,  371 
of  hysteria,  348-362 
of  idiocy,  435 
of  insomnia,  91 
of  intercostal  neuralgia,  162 
of  locomotor  ataxia,  192 
of  mania,  406 
of  migraine,  82 
of  multiple  sclerosis,  314 
of  myxcedema,  389 
of  neuralgia,  85 

of  fifth  cranial  nerve,  127,  128 
of  neurasthenia,  341-345 
of  neuritis  of  sciatic  nerve,  169 
of  occupation-neuroses,  367 
of  optic  neuritis,  109 
of  parsesthesia,  87 
of  paralysis  agitans,  323 

of  brachial  plexus,  158 

of  circumflex  nerve,  151 

of  facial  nerve,  132 

of  fifth  cranial  nerve,  124-126 

of  intrascapular  nerve,  151 

of  lumbar  plexus,  164 

of  median  nerve,  156 


INDEX. 


453 


Symptoms  of  paralysis  of  muscles  sup- 
plied by  third  cranial  nerve, 115 
of  rausculo-cutaneous  nerve,  154 
of  musculo-spiral  nerve,  154 
of  phrenic  nerve,  149 
of  posterior  thoracic  nerve,  151 
of  sacral  plexus,  165 
of  spiual  accessory  nerve,  143 
of  twelfth  nerve,  147 
of  ulnar  nerve,  15t),  157 
of  paranoia,  411 
of  paretic  dementia,  419 
of  primary  brachial  neuritis,  159 

lateral  sclerosis,  198 
of    progressive    neurotic    niuscitlar 

atrophy,  218 
of  Raynaud's  disease,  376 
of  serous  meningitis,  184 
of  softening  of  brain,  262 
of  spastic  hemiplegia,  200 
of  spastic  paraplegia,  202 
of  Sydenham's  chorea,  326 
of  syphilis  of  nervous  system,  317 
of  syringomyelia,  309-311 
of  tetanus,  369 
of  tetany,  372 
of  tic  convulsif,  331 
of  traumatic  neuroses,  364 
of  tubercular  meningitis,  183 
of  tumors  of  spinal  cord,  306 
of  vertigo,  89 
Syphilis  of  nervous  system,  316-322 
acquired,  316 
diagnosis,  320 
hereditary,  316 
parasyphilitic  conditions,  316 
pathology,  317 
endarteritis,  317 
gummata,  317 
gummatous  meningitis,  317 
peri-arteritis,  317 
prognosis,  321 
specific  conditions,  316 
symptoms,  317 

cerebral  syphilis,  318 
syphilis  of  cord,  319 
Erb's  type,  319 
of  nerves,  320 
treatment,  321 
Syphilitic  leptomeningitis,  187 
Syringomyelia,  308-312 
definition,  308 
diagnosis,  312 
etiology,  309 
morbid  anatomy,  309 
symptoms,  309-311 
treatment,  312 
System  diseases,  190-231 


T. 

Tabes  dorsalis  (see  Locomotor  ataxia). 

190-197 
Taste,  examination  of,  49 
Temperature-sense,  44 

loss  of,  46 
Tendon  reflexes,  51 
Tetanus,  369 
cephalic,  370 
symptoms,  369 
treatment,  370 
Tetany,  372 
etiology,  372 
symptoms,  372 
treatment,  374 
Thomson's  disease,  375 
Tic  convulsif,  135,  331 
etiology,  331 
symptoms,  331 
treatment,  332 
douloureux,  127 
Tics,  35 
Tinnitus,  136 
Titubation,  47 
Tobacco-amblyoiiia,  108 
Tongue,  paralysis  of,  41 
Torticollis,  143 

ToxEemia  as  a  cause  of  headache,  78 
Toxic  amaurosis,  108 
Tracts,  22-30 
association-,  23 
motor,  24 

crossed  pyramidal,  25 
direct  pyramidal,  26 
function,  26 
indirect,  27 
internal  capsule,  24 
symptoms  of  destructive  lesions 
of,  39-42 
of  overaction  of,  34-39 
proj  ection-fibres,  22 
sensory,  27 
collaterals,  30 

method  of  examination,  45,  46 
muscles,  28 
pain,  29 

symptoms  of  destructive  lesions 
of,  43-45 
of  irritative  lesions  of,  42,  43 
temperature,  29 
touch,  27 
Treatment  of  acromegaly,  386 

of  acute  anterior  i)oliomyelitis,  209 
ascending  paralysis,  216 
bulbar  palsy,  21 
myelitis,  301 
oplithalnioplegia,  121 


454 


INDEX. 


Treatment   of  acute   simple  cerebral 
meningitis,  181 
spinal  leptomeningitis,  189 

of  alcoholic  meningitis,  186 

of    amyotrophic    lateral    sclerosis, 
225 

of  arthritic  muscular  atropliy,  217 

of  asthenic  bulbar  palsy,  215 

of  ataxic  paraplegia,  227 

of  brachial  neuralgia,  162 

of  brain-abscess,  269 
-tumors,  281 

of  cerebral  hemorrhage,  261 
palsies  of  children,  205 

of  cervico-occipital  neuralgia,  149 

of  chronic  cerebral  leptomeningitis, 
187 
hydrocephalus,  188 
myelitis,  303 
ophthalmoplegia,  121 
progressive  bulbar  palsy,  214 
spinal  leptomeningitis,  189 

of  compression-myelitis,  304 

of  diseases  of  tenth  cranial  nerve, 
142 

of   epidemic  cerebro-spinal   menin- 
gitis, 183 

of  epilepsy,  339,  340 

of  erythromelalgia,  171 

of  facial  spasm,  136 

of  headache,  81 

of  hereditary  chorea,  331 

of  hydrophobia,  372 

of  hysteria,  363 

of  idiocy,  437 

of  insomnia,  91 

of  intercostal  neuralgia,  163 

of  locomotor  ataxia,  196 

of  mania,  409 

of  Meniere's  disease,  90 

of  migraine,  84 

of  multiple  neuritis,  105 
sclerosis,  316 

of  muscular  dystrophies,  222 

of  myxcedema,  390 

of  neuralgia,  86 

of  fifth  cranial  nerve,  128-130 

of  neurasthenia,  346 

of  neuritis  of  sciatic  nerve,  170 

of  occupation-neuroses,  369 

of  optic  neuritis,  110 

of  parspsthesia.  88 

of  paralysis  agitans,  325 
of  facial  nerve,  134 
of  fifth  cranial  nerve,  1:26 
of  phrenic  nerve,  150 
of  spinal  accessory  nerve,  143 
of  spinal  nerves,  168 


Treatment    of   paralysis    of    twelfth 
nerve,  147 

of  paranoia,  413 

of  pressure-palsy,  94 

of  primary  brachial  neuritis,  160 

of  primary  lateral  sclerosis,  199 

of    progressive    neurotic    muscular 
atrophy,  219 

of  Eaynaud's  disease,  378 

of  serous  meningitis,  185 

of  softening  of  brain,  264 

of  spasms   of  muscles  supplied  by 
spinal  accessory  nerve,  146 

of  spastic  hemiplegia,  205 

paralysis,  hereditary,  206 
paraplegia,  205 

of  Sydenham's  chorea,  329 

of  syphilis  of  nervous  system,  321 

of  syringomyelia,  312 

of  tetanus,  370 

of  tetany,  374 

of  tic  convulsif,  332 

of  traumatic  neuroses,  364 

of  tubercular  meningitis,  184 

of  tumors  of  spinal  cord,  308 

of  vertigo,  90 
Tremor,  36 

causes,  38 

character,  38 

convulsive,  332 

examination-,  36 

fibrillary,  36 

of  hysteria,  361 

intention-,  36 
Trismus,  369 
Trophic  disturbances,  54 
Tubercular  leptomeningitis,  181 

meningitis,  183 
Tumors  of  brain,  269 

of  spinal  cord,  305-308 

u. 

Urination,  reflexes,  53 

V. 

Vagus  nerve  (see  Nerves),  138 
Vaso-motor  symptoms,  54 
Verbigeration,  431 
Vertigo,  88-91 
auditory,  89 
diagnosis,  90 
etiology,  89 
aural  disturbances,  89 
circulatory  disturbances,  89 
mechanical  conditions,  89 
neuropathic  conditions,  89 


INDEX. 


455 


Vertigo,  etiology,  toxemic  couditions, 
89 
visual  defects,  89 
pathology,  88 
symptoms,  89 
objective,  89 
subjective,  89    ■ 
treatment,  90 
of  the  attack,  90 
of  the  cause,  90 
Visceral  reflexes,  53 


Wo 

Waking-Dumbiiess,  8(i 

Wernicke's  pupillary  inactiou-sigUjllS 

Word-bliuduess,  242 

Word-deafness,  242 

Writers'  cramp,  367,  368 

paralytic,  367 

spasmodic,  367 

tremulous,  367 
Wry-neck,  143 


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cl..a.ssifie:d  index 

ANATOMY.     Gray,  Gerrish,Woolsey,  Huntington,  Eckley,  Treves,   Rockwell. 

BACTERIOLOGY.      Abbott,  Park,  ZaptFe,  Archinard. 

BLOOD.     Ewing. 

CHEMISTRY.    Simon  (W.),  Simon  (C.  E.),  Attfield,   Martin    &   Rockwell, 

Remsen,  Vaughan  &  Novy,  McGlannan. 
CLIMATOLOGY.     Solly,  Hayem  &  Hare. 
DENTISTRY.     Essig  (Prosthetic),  Kirk  (Operative),  Burcliard,  Essig  &  Koeiiig 

(Metallurev),  Long,  American  System,  Coleman. 
DERMATOLOGY.     Hyde  &  Montgomery,   Jackson,  Pye-Smith,   Jamieson, 

Hardaway,  Grindon,  Schalek. 
DIAGNOSIS.     Musser,  Hare,  Simon,  Herrick,  Le  Fevre,  Findley,  Arneill. 
DICTIONARIES.     Dunglison,  Duane,  Hoblyn,  Billings  (National). 
DISPENSATORY.     National. 
ELECTRICITY.     Allen,  Potts. 
FORMULARY.     Page  32. 

FRACTURES  and  DISLOCATIONS .     Stimson,  Pick. 
GYNECOLOGY.     Dudley,  Findley,  Crockett,  Davenport,  American  System, 

Thomas  &   Munde,  Emmet. 
HISTOLOGY.  Dunham, Szymonowicz,  Klein,  Schafer,  Nichols  &  Vale.Wathen. 
HYGIENE.     Harrington,  Egbei't,  Richardson. 

LARYNGOLOGY  a  Qd  RHINOLOGY.  Posey  &  Wright,  Grayson,  Coakley. 
MATERIA  MEDICA.     Hare.  Culbreth,  Schleif,  Bruce,  Maisch,  Long. 
MEDICAL  JURISPRUDENCE.    Taylor,  Dwight. 

NERVOUS  AND  MENTAL  DISEASES.    Starr,  Potts,  Nagel,  Clouston. 
OBSTETRICS.     .lewett,  Davis,  Reynolds  &  Newell,  King,  Playfair,  Evans, 

Manton,  American   System. 
OPHTHAL3IOLOGY.     Posey  &  Wright,  Veasey,  Suter,  Nettleship,  Norris  & 

Oliver,  Ballenger  &  Wippern,  Juler,  Ailing  &  Griffen. 
OTOLOGY.     Politzer,  Posey  &  W  right,  Grayson,  Bacon,  Ballenger  &  Wippern, 

Burnett,  Field,  Ferguson. 
PATHOLOGY.      Schmaus,  Green,  Ewing,  Nichols  &  Vale,  Coats. 
PEDIATRICS.     Koplik,  Williams,  Tuttle.  Tuley,  Smith. 
PHARMACOLOGY.      Hare,  Cushny,  Culbreth,  Hermann. 
PHARMACY.     Caspari. 

PHYSICS.     Draper,  Martin  &  Rockwell,  McGlannan. 
PHYSIOLOGY.      Hall,    Chapman,    Collins    &    Rockwell,    Foster,    Dalton, 

Guenthers. 
PRACTICE.    Thompson,  Roger,  Malsbary,  Loomis  &  Thompson,  Flint,  Kelly. 
PROGRESSIVE  MEDICINE.    Page  32. 
RADIOTHERAPY.     Allen. 
SEXUAL  DISORDERS.     Morrow,  Taylor. 
STATE  BOARD  EXAMINATION  SERIES.     Page  26. 
SURGERY,    von  Bergiiiann,  Park,  Brewer,  Roberts,   Cheyne   &   Burghard, 

Treves,  Ashhurst,  Gallaudet,  Richardson,  Magee  &  .lohnsou,  Wharton. 
SURGERY— OPERATIVE.    Stimson,  AVharton,  Treves,  Smith. 
SURGERY— ORTHOPEDIC.     Whitman. 
THERAPEUTICS.     Hare,  Schleif,  Cushny,  Fothergill.Whitla,  Hayem  &  Hare, 

Bruce,  Tirard,  Long. 
URINARY  DISEASES.    Taylor,  Roberts,  Black. 

VENEREAL  DISEASES.   Taylor,  Morrow,  Hayden,  Schmidt,  Fuller,  Cornil. 
VISITING  LIST.     Page  32. 
7-1-04 


2       Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

ABBOTT  f  A.  C).  PRINCIPLES   OF   BACTERIOLOGY:  a  Practical 

Manual    for   Students    and    Physicians.      Sixth   edition   thoroughly 

revised  and  greatly  enlarged.    12mo.  636  pages,  with  111  engravings, 

of  which  26  are  colored.    Cloth,  $2.75,  net. 

This  book  has  been  adopted  as  a    asthemostsuitable  work  from  which 

standard   text-hook  on  bacteriology    to  gain  a  knowledge  of  its  science. 

in  nearly  all   the  medical    colleges    It  is  accurate,  concise,  clear  and  at- 

in  the  United  States,  and  not  only    tractive. — The  NeivYork  State  Jour- 

this,  but  it  has  been  also  generally    nal  of  Medicine. 

accepted  by  the  medical  profession 

AliliEN  (CHARLiES  W.).  RADIOTHERAPY,  PHOTOTHERAPY 
AND  HIGH  FREQUENCY  CURRENTS.  The  Medical  and  Sur- 
gical Applications  of  Radiology  in  Diagnosis  and  Treatment.  Octa- 
vo, 618  pages,  131  engravinsts  and  27  full-page  colored  plates.  Cloth, 
$4.50,  net. 

ALLEN  (HARRISON).  A  SYSTEM  OF  HUMAN  ANATOMY; 
WITH  AN  INTRODUCTORY  SECTION  ON  HISTOLOGY,  by 
E.  0.  Shakespeare,  M.D.  Comprising  813  double-columned  quarto 
pages,  with  380  engravings  on  stone,  109  plates,  and  241  wood  cuts 
in  the  text.     One  volume,  cloth,  $23. 

AtiLING  (ARTHUR  N.)  and  GRIPFEN  (O.  A.).  AN  EPITOME 
OF  EYE  AND  EAR  DISEASES.  12mo,  about  225  pages,  with  82 
engravings.  Cloth  $1.00,  net.  Shortly.  See  Lea's  Series  of  Medical 
Epitomes,  page  IS. 

AMERICAN  SYSTEM  OF  PRACTICAL  MEDICINE.  A  SYS- 
TEM OF  PRACTICAL  MEDICINE.  In  contributions  by  Various 
American  Authors.  Edited  by  Alfred  L.  Loomis,  M.D.,  LL.D., 
and  W.  Gilman  Thompson,  M.  D.  In  four  very  handsome  octavo 
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For  sale  by  subscription  only.     Prospectus  free  on  application. 

AMERICAN  SYSTEM  OF  DENTISTRY.  In  treatises  by  various 
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handsome  super-royal  octavo  volumes,  containing  about  3200  pages, 
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AMERICAN  SYSTEMS  OF  GYNECOLOGY  AND  OBSTET- 
RICS. By  eminent  American  specialists.  Gynecology  edited  by 
Matthew  D.  Mann,  A.M.,  M.D.,  and  Obstetrics  edited  by  Barton 
C.  Hirst,  M.D.  In  four  octavo  volumes,  comprising  3612  pages, 
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leather,  $6;   half  Russia,  $7.     Prospectus  free  on  request, 

AMERICAN    TEXT-BOOK    OF    OPERATIVE   DENTISTRY, 

Edited  by  Edward  C.  Kirk,  D.D.S. ,  Professor  of  Clinical  Dentistry, 
Department  of  Dentistry,  University  of  Pennsylvania.  Second  edition. 
857  pages,  897  engravings      Cloth,  $6 ;  leather,  $7,  net. 


Written  by  a  number  of  practi- 
tioners as  well  known  at  the  chair 
as  in  journalistic  literature,  many  of 
them  teachers  of  eminence  in  our 
colleges.  It  should  be  included  in 
the  list  of  text-books  set  down  as 
most  useful  to  the  college  student. — 
The  Dental  News. 


It  is  replete  in  every  particular 
and  treats  the  subject  in  a  progressive 
manner.  It  is  a  book  that  every 
progressive  dentist  should  possess, 
and  we  can  heartily  recommend  it 
to  the  profession. —  The  Ohio  Dental 
Journal. 


Lea  Bkotheks  &  Co.,  Philadelphia  and  New  York.       3 

AMERICAN  TEXT-BOOK  OF  ANATOMY.     See  Gerrish,  page  11. 

AMERICAN  TEXT-BOOK  OF   DENTAL  PATHOLOGY.     See 

Biirchard,  page  5. 

AMERICAN  TEXT-BOOK  OF  DENTAL  MATERIA  MEDICA 
AND  THERAPEUTICS.     See  Long,  page  IS. 

AMERICAN  TEXT-BOOK  OF  PROSTHETIC  DENTISTRY. 

In  Contributions  by  Eminent  American  Authorities. 

Edited  by  Charles  J.  EssiG,  M.D.,  D.D.S.,  Professor  of  Mechanical 
Dentistry  and   Metallurgy,  Department  of  Dentistry,  University  of 
Pennsylvania,  Philadelphia.    Second  edition.    807  pages,  1089  engrav- 
ings.    Cloth,  $6 ;  leather,  $7,  net. 
No  more  thorough  production  will  I      It  is  up  to  date  in  every  particular, 
be  found  either  in  this  country  or  in    It  is  a  practical  course  on  prosthetics 
any  country  where  dentistry  is  un-    which  any  student  can  take  up  dur- 
derstood  as  a  part  of  civilization. —  i  ing  or  after  college. — Dominion  Deri' 
The  Intemaii&nal  Dental  JoumaL    !  tal  Journal. 

A   TREATISE   ON   SURGERY  BY   AMERICAN  AUTHORS. 

FOR  STUDENTS  AND  PRACTITIONERS  OF  SURGERY  AND 
MEDICINE.    Edited  by  Roswell  Park,  M.D.     See  page  21. 

ARCHINARD  (P.  E.).    AN    EPITOME    OF    MICROSCOPY    AND 

BACTERIOLOGY.    12mo,  240  pages,  with  74  illustrations.  Cloth,  $1, 
net.     Lea's   Series   of  Medical  Epitomes.     See  page  18. 

ARNEILL  (JAMES  R.).  AN  EPITOME  OF  CLINICAL  DIAG- 
NOSIS AN  D  URINALYSIS.  See  Lea's  Series  of  Medical  Epitomes. 
Page  18. 

ASHHURST  (JOHN,  JR.).  THE  PRINCIPLES  AND  PRACTICE 
OF  SURGERY.  For  the  use  of  Students  and  Practitioners.  Sixth 
and  revised  edition.  In  one  large  and  handsome  octavo  volume  of 
1161  pages,  with  656  engravings.   Cloth,  $6 ;  leather,  $7. 

As  a  masterly  epitome  of  what  has  text-book,  we  do  not  know  its  equal, 

been  said  and  done  in  surgery,  as  a  It  is  the   best  single  text-book  of 

succinct  and  logicaJ  statement  of  the  surgery  that  we  have  yet  seen  in  this 

principles  of  the  subject,  as  a  model  country. — New  York  Dost- Graduate. 

ATTFEELD  (JOHN).  CHEMISTRY ;  GENERAL,  MEDICAL  AND 
PHARMACEUTICAL.  Sixteenth  edition,  specially  revised  by  the 
Author  for  America.  In  one  handsome  12iho.  volume  of  784  pages, 
with  88  illustrations.    Cloth,  $2.50,  net. 

It  is  replete  with  the  latest  inform-    or  in  general  practice. — The  Pitts- 
ation,  and  considers  the  chemistry  of    burg  Medical  Review. 
every  substance  recognized  officially 

BACON  (GORHAM).     ON   THE   EAR.    Third  edition.    One  12mo. 

volume,   430  pages,   120  engravings  and   7   colored    plates.     Cloth, 

net,  .$2.25. 

It  is  the  best  manual  upon  otology,    which  will  be  found  of  the  highest 

An  intensely  practical  book  for  stu-    utility  to  both  the  medical  student 

dents  of  medicine — Cleveland  Jour-    and  practitioner.     This  book  is  sure 

nal  of  Medicine.  to  commend  itself  to  the  specialist  as 

The  book  is  practically  a  new  one    well. — St.  Louis  Medical  and  Sur- 

and  thoruughly  up-to-date — a  book  \  fjical  Journal. 

BARNES  (ROBERT  AND  FANCOURT).  A  SYSTEM  OF  OB- 
STETRIC MEDICINE  AND  SURGERY.  Octavo,  872  pages,  with 
231  illufl.     Cloth,  $5  :  leather,  $6. 


4       Lba  Brothers  &  Co.,  Philadelphia  and  New  York. 

BALiLENGER  (W.   L.)  AND  WIPPERN   (A.  G.).     A   POCKET 

TEXT-BOOK  OF  DISEASES  OF  THE   EYE,  EAR,  NOSE  AND 

THROAT.     In   one  handsome  12mo.  volume  of  525  pages,  with  148 

illustrations,  and  6  colored  plates.     Cloth,  $2.00,  net;  limp  leather, 

$2.50,  net.     See  Lea's  Series  of  Pocket  Text-books,  p.  18. 

Like    the  other  volumes  of  this   to  write  upon  the  subjects  they  have 

series,  this   is  compendious  and  re-   chosen,  and  they  have  done  so  in  a 

plete  with  information   of  the  sort   manner  which  makes  the  book    a 

needed   by   the   student  and  practi-    valuable  one.  —  St.   Louis   Medical 

tioner.  The  authors  are  fully  qualified    and  Surgical  Reporter. 

BARTHOLOW  (ROBERTS).  CHOLERA;  ITS  CAUSATION,  PRE- 
VENTION AND  TREATMENT.  In  one  12mo.  volume  of  127  pages, 
with  9  illustrations.     Cloth,  $1.25. 

BERGMANN'S  SURGERY.     See  von  Bergmann,  page  30. 

BLLLINGS  (JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONARY. 
Including  in  one  alphabet  English,  French,  German,  Italian  and 
Latin  Technical  Terms  used  in  Medicine  and  the  Collateral  Sciences. 
In  two  octavo  volumes  containing  1574  pages  and  two  colored  plates. 
Per  volume,  cloth,  $6 ;   leather,  $7. 

BLACK  (D.  CAMPBELL).      THE    URINE    IN    HEALTH    AND 

DISEASE,  AND  URINARY  ANALYSIS,  PHYSIOLOGICALLY 

AND  PATHOLOGICALLY  CONSIDERED.     In  one  12mo.  volume 

of  256  pages,  with  73  engravings.     Cloth,  $2.75. 

A  concise,  yet  complete  manual,  i  tical  and  clinical  standpoint. — The 

treating  of  the  subject  from  a  prac-  |  Ohio  Medical  Journal. 

BLOXAM  (C.  L.).    CHEMISTRY,  INORGANIC  AND  ORGANIC. 

With  Experiments.  New  American  from  the  fifth  London  edition. 
In  one  handsome  octavo  volume  of  727  pages,  with  292  illustrations. 
Cloth,  $2 ;  leather,  $3. 

BREWER  (GEORGE  E.).  A  TEXT-BOOK  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  SURGERY.  Octavo,  700  pages,  280  engrav- 
ings, 7  colored  plates.  Cloth,  $4;  leather,  $5,  net;  half  Morocco, 
$5.50,  net.     Just  ready. 


This  volume  presents  the  essential 
facts  of  surgery  in  a  comprehensive, 
clear  and  concise  manner.  The  book 
is  a  scientific  exposition  of  modern 
surgery,  and  the  reviewer  has  no 
hesitancy  in  saying  that  it  is  the 
best  surgical  text-book  in  print  by 
an  American  author.  The  author 
presents  a  practical,  common-sense 
and  yet  highly  scientific  work.     We 


heartily  commend  the  book  not  only 
to  students  but  also  to  practitioners. 
— St.  Paul  Medical  Journal. 

The  author's  intensely  practical 
treatment  of  this  comprehensiTC  sub- 
ject, combined  with  brevity  and 
definite  clearness  of  statement,  at 
once  compels  the  reader's  attention 
and  bespeaks  the  success  of  the  work. 
— Medical  Review  of  Reviews. 


BRUCE   (J.  MITCHELL).     MATERIA  MEDICA  AND  THERA- 
PEUTICS.     Sixth  edition.     In    one   12mo.  volume    of   600  pages. 
Cloth,  $1.50,  net.    See  Student's  Series  of  Manuals,  page  27. 
This  new    edition    increases    the  I  known    and    appreciated. — Medical 
value  and  more  firmly  establishes    Revieiv  of  Reviews. 
the  reputation  of   a  work  already  I 

BRUCE   (J.  MITCHELL).    PRINCIPLES  OF  TREATMENT.     In 

one  octavo  volume  of  625  pages.     Cloth,  $3.75,  net. 


One  of  the  most  useful  books  in 
vhich  the  practitioner  can  invest. 
It  is  a  book  worthy  of  reading  from 


cover  to  cover. —  Virginia  Medical 
Semi-Monthly. 


Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek.       5 


BRYANT  (THOMAS),  THE  PRACTICE  OF  SURGERY.  Fourth 
American  from  the  fourth  English  edition.  In  one  imperial  octavo  vol- 
unie  of  1040  pages,  with  727  illustrations.    Cloth,  $6.50 ;  leather,  $7.50. 

BURCHARD  (HENRY  H.).    DENTAL  PATHOLOGY.    New  (2nd) 

edition,  thoroughly  revised  by  Otto  E.    Englis,    D.D.S.     Handsome 
octavo,  about  600  pages,  with  about  450  illustrations.     Rearli/  shortly. 

BURNETT  (CHARLES  H.).  THE  EAR :  ITS  ANATOMY,  PHYSI- 
OLOGY AND  DISEASES.  A  Practical  Treatise  for  the  Use  of 
Students  and  Practitioners.  Second  edition.  In  one  8vo.  volume  of 
580  pages,  with  107  illustrations.     Cloth,  $4 ;  leather,  $5. 

CARTER  (R.  BRUDENELL)  AND  FROST  (W,  ADAMS).  OPH- 
THALMIC SURGERY.  In  one  pocket-size  12mo.  volume  of  559 
pages,  with  91  engravings  and  one  plate.  Cloth,  $2.25.  See  Series  of 
Clinical  Manuals,  page  25. 

CASPAR!   (CHARLES   JR.).     A  TREATISE   ON   PHARMACY. 

For  Students  and  Pharmacists.  Second  edition.  In  one  handsome 
octavo  volume  of  774  pages,  with  301  illustrations.  Cloth,  $4.25  nei. 
In  a  single  comprehensive  volume  !  ers  instruct  from  it  with  economy 
he  presents  the  l)ody  of  information  !  in  time  and  effort.  Pharmacists 
which  to-day  constitutes  the  science  :  will  find  it  a  most  useful  guide  in 
and  practice  of  pharmacy  in  its  pre-  the  oijerations  of  their  calling  and 
sent  advanced  state.  It  is  homo-  in  the  interpretation  of  the  Phar- 
geneous,  uniform,  clear  and  accur-  ;  macopceia. — The  Sa7i  Francisco  and 
ate.     Students  can  learn  and  teach-  !  Pacific  Druggist. 

CHAPMAN  (HENRY  C).  A  TREATISE  ON  HUMAN  PHYSI- 
OLOGY. Second  edition.  In  one  octavo  volume  of  921  pages, 
with  595  illustrations.     Cloth,  $4.25 ;  leather,  $5.25,  net. 


In  every  respect  the  work  fulfils 
its  promise,  whether  as  a  complete 
treatise  for  the  student  or  as  an  ad- 


mirable work  of  reference  for  the 
physician. — North  Carolina  Medical 
Journal. 


CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIO- 
LOGICAL AND  PATHOLOGICAL  CHEMISTRY.  Octavo,  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE  (W.  W.)  AND  BURGHARD  (P.  P.).  SURGICAL 
TREATMENT.  In  seven  octavo  volumes,  containing  2908  pages 
with  827  engravings,  Volume  I.,  cloth,  $3.00  net.  Volume  II.,  cloth, 
$4.00  net.  Vol.  Ill,  cloth,  $3.50,  net.  Vol.  IV.,  cloth,  $3.75,  net. 
Vol.  v.,  cloth,  $5.00,  net.  Vol.  VI.,  cloth,  $5.00,  net.  Vol.  VII., 
cloth,  $5.75,  net. 
The  book  differs  from  all  other  i  after  operation,  including  the  con- 
works    on    surgery    in    the  English  ]  duct  of  the  treatment   in    the    face 


language  by  confining  itself  strictly 
to  practical  considerations.  There 
is  no  theory  of  disease  or  its  causa- 
tion—nothing but  the  treatment  of 
2)atients  suffering  from  surgical  dis- 
ease, once  the  diagnosis  is  made. 
The  treatment  of  patients  before  and  ' 

CLELAND  (JOHN).     A  DIRECTORY  FOR  THE  DISSECTION  OF 
THE  HUMAN  BODY.     In  one  12mo.  vol.  of  178  pages.    Cloth,  $1.25. 

CLINICAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  25. 


of  any  of  the  emergencies  of  surgi- 
cal pratice.  is  fully  set  forth.  The 
vast  material  on  which  the  authors 
have  di-awn  for  their  deductions 
gives  the  book  an  unusual  value. 
— Medical  News. 


6      Lka  Bkothebs  &  Co.,  Philadelphia  and  New  York. 


CLOUSTON  {THOMAS  S.).  CLINICAL  LECTURES  ON  MENTAL 
DISEASES.  New  (5th)  edition.  In  one  octavo  volume  of  750  pages, 
with  19  colored  plates.     Cloth,  $4.25,  net. 

COAKL-EY  (CORNELIUS  G.).  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  NOSE,  THROAT,  NASO- 
PHARYNX AND  TRACHEA.  Second  edition.  In  one  12mo. 
volume  of  556  pages,  with  103  engravings  and  4  colored  plates.  Cloth, 
$2.75.  net. 


It  is  the  best  condensed  manual 
that  has  recently  appeared. — Boston 
Medical  and  Surgical  Journal. 

Dr  Coakley  devotes  especial  at- 
tention to  the  practical  points,  such 
as  ex-imiuation,  diagnosis  and  treat- 
ment, tliere))y  making  a  valuable 
acquisition   to    the    library   of   the 


student  and  general  practitioner.  A 
special  chapter  on  therapeutics  has 
been  added,  Avhich  contains  a  classifi- 
cation of  drugs  according  to  their 
local  action,  and  a  number  of  useful 
prescriptions,  with  indications  as  to 
their  use. — The  Ka72sas  City  Med- 
ical Index-Lancet. 


COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  vol' 
of  829  pages,  with  339  engravings.     Cloth,  $5.50;  leather,  $6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY 
AND  PATHOLOGY.  With  Notes  and  Additions  to  adapt  it  to  Amer- 
ican Practice.  By  Thos.  C.  Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one 
handsome  octavo  vol.  of  412  pages,  with  331  engravings.    Cloth,  $3.25. 

COLLINS  (C.  F.)  and  DAVIS  (F.).  A  POCKET  TEXT-BOOK 
OF  MEDICAL  DIAGNOSIS.  Preparing.  See  Lea's  Series  of 
Pocket  Text-Books,  page  18. 

COLLINS   (H.   D.)  AND   ROCKWELL    (W.    H.).      A  POCKET 

TEXT-BOOK   OF  PHYSIOLOGY.      12mo.  of  316  pages,  with  153 

illustrations.       Cloth,  $1.50;    flexible  red  leather,  $2.00,  net.       See 

Lea's  Series  of  Pocket   Text-books,  page  18. 

Well  written  and  up  to  date.     It    practitioner  with  the  advances   in 


this    subject. — The    Physician    and 
Surgeon. 


is  a  manual  admirably  adapted  to 
teach  the  beginner  the  essentials  of 
physiology,    and    to    acquaint    the 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In 
one  large  8vo.  volume  of  719  pages.     Cloth,  $5.25. 

CORNIL  (V.).    SYPHILIS :  ITS    MORBID    ANATOMY,  DIAGNO- 
SIS AND  TREATMENT.    Translated,  with  Notes  and  Additions,  by 
J.  Henr^  C.  Simes,  M.D.  and  J.  William  White,  M.  D.    In  one 
■    8vo.  volume  of  461  pages,  with  84  illustrations.     Cloth,  $3.75. 

CROCKETT  (M.  A.).  A  POCKET  TEXT-BOOK  OF  DISEASES 
OF  WOMEN.  In  one  handsome  12mo.  volume  of  368  pages,  with 
107  illustrations.  Cloth,  $1.50,  net;  flexible  leather,  $2.00,  net. 
See  Lea's  Series  of  Pocket  Text-books,  page  18. 


book    for   pi'actitioners. — St.  Louit 
Medical  and  Surgical  Journal. 


This  is,  like  all  the  other  manuals 
in  this  series,  a  most  excellent  guide 
for  students  and  a  handy  reference 

CROOK    (JAMES      K.)    ON     MINERAL     WATERS     OF     THE 
UNITED  STATES.     Octavo,  575  pages.     Cloth,  $3.50,  net. 
In  such  a  book  as  this  the  medical    of  every  water  of  any  known  medici- 
profession  will  find  a  wonderful  ally ;    nal    properties. — The    Louisville 
it  is  remarkably  complete  in  every    Monthly  Journal. 
detail,  giving  the  results  of  analyses  1 


Lea  Beothees  &  Go.,  Philadelphia  and  New 


CULBRETH  (DAVID  M.  R.).    MATERIA  MEDICA  AND  PHAR- 
MACOLOGY.     Third   edition.      In    one   handsome   octavo   volume 
of  90.5  pages,  with  47;i  illustrations.     Cloth,  ,$4.75,  net. 
A  systematic  and  thorough  treatise   on  the  entire  Materia  Medica, 

animal,  vegetable  and  mineral.     In  detail  and  abundance  of  information, 

as  well  as  richness  of  illustration,  this  convenient  volume  has  no  parallel 

on  its  subject. 

CUSHNY    (ARTHUR  R.).   TEXT-BOOK  OF  PHARMACOLOGY. 

Third  edition.     Handsome  8vo.,   750  pages,  with  52  illustrations. 

Cloth,  $3.75,  net ;    leather,  $4  75,  net. 
The  best  exposition  of  our  knowl-    acquaintingthemselves  with  the  very 
edge  of  pharmacology  which  has  yet    latest  knowledge   on  this  very  im- 
been  given  to   the  medical   public,    portant  subject.— TZ/ei/onirea/ ifed- 
We  can  cordially  recommend  it  to    ical  Journal. 
all  our  readers  who  are  desirous  of 

DAJLTON  (JOHN  C).    A  TREATISE  ON  HUMAN  PHYSIOLOGY. 

Seventh  edition.  Octavo,  722  pages,  with  252  engravings.  Cloth. 
$5 ;  leather,  $6.  s  s 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.   In 

one  handsome  12mo.  volume  of  293  pages.     Cloth,  .$2. 

DAVENPORT  (P.  H.).      DISEASES  OF  WOMEN.      A   Manual  of 
Gynecology.      For    the  use  of  Students  and   Practitioners.    Fourth 
edition.     In  one  handsome   12mo.   volume    of   402    pages,  with   154 
illustrations.     Cloth,  $1.75,  net. 
Dr.    Davenport    has    the    happy    knowing,  and  presents  these  princi- 
faculty  of  selecting  just  those  points  \  pies  in  a  clear,  concise  and  thorough 
in  gynecological  therapeutics    and  ■  manner.     The  book  can  be  highly 
surgery  which  the  student  and  junior   commended.— TAe  3Iedical  Age. 
practitioner  most  stand  in  need  of 

DAVIS  (EDWARD  P.).      A  TREATISE  ON  OBSTETRICS.     FOR 

STUDENTS    AND    PRACTITIONERS.      New    (2nd)     edition, 
thoroughly  revised.     In  one  very  handsome  octavo    volume    of  800 
pages,  with  274  engravings  and  39'full-page  plates  in  colors  and  mono- 
chrome..    Cloth,  $5.00,  net ;  leather,  $6.00,  7iet.     Just  ready. 
The  author  has  fully  utilized  the  opportunity  presented  by  the  demand  for 
another  edition  of  his  well  known  work,  and'has  subjected  it  to  a  thorough 
revision.      It  is  a  succinct  and   clear  presentation  of  modern  obstetrics, 
with  ample  illustration. 

DAVIS  (F.  H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second 
edition.     In  one  12mo.  volume  of  287  pages.     Cloth,  $1.75. 

DAYTON  (HUGHES).    AN  EPITOME  OF   THE   PRACTICE   OF 

MEDICINE.     See  Lea's  Series  of  Medical  Epitomes,  page  18. 

DE  liA  HECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  octavo 
volume  of  700  pages,  with  300  engravings.     Cloth,  $4. 

DE  SOHWEINITZ  (GEORGE  E.).    THE  TOXIC  AMBLYOPIAS. 

Their  Classification,  History,  Symptoms,  Pathology  and  Treatment. 
Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page 
plates  in  colors.     De  luxe  binding,  $4,  net. 

DRAPER  (JOHN  C).  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  volume 
of  734  pages,  with  376  engravings.     Cloth,  $4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  Twelfth  Edition.  Octavo,  965  pages,  with 
373  engravings.     Cloth,  $4 ;  leather,  $5. 


8      Lea  Brothees  &  Co.,  Philadelphia  and  New  York. 


DUANE  (ALEXANDER).    A  DICTIONAEY  OF  MEDICINE  AND 
THE  ALLIED  SCIENCES.     Comprising  the  Pronunciation,  Deriva- 
tion and  Full  Explanation  of  Medical,  Dental,  Pharmaceutical  and 
Veterinary  Terms.     Together  with  much  Collateral  Descriptive  Mat- 
ter, Numerous  Tables,  etc.     Fourth  edition,  with  appendix.     Square 
octavo  of  688  pages,  with  8  colored  plates  and  thumb   index.     Cloth, 
$3.00.  net ;  limp  leather,  $4.00.  net. 
It  is  one  of  the  modern  marvels  |  purse.     For  the  student  and  busy- 
that  such  a  vast  aggregate  of  schol-    practitioner  it  is  decidedly  the  best 
arly  knowledge  can  be  placed  with-    book    in    its     line. — The    Southern 
in  the  command  of  a  very  modest   Practitioner. 

DUDLEY    (E.    C).      THE    PRINCIPLES    AND    PRACTICE     OF 
GYNECOLOGY.     New  (4th)  edition,  thoroughly  revised.     Handsome 
octavo  of  770  pages,  with  420  illustrations  in  black  and  colors,  and 
16  colored  plates.     Cloth,  $5.00,  net;  leather,  $6.00,  net;  half  Moroc- 
co, $6.. 30,  net.     Just  ready. 
The  marked  success  of  this  book  is  owing  to  its  reduction  of  Gynecology 
to  a  rational  basis  and  its  consequent  simplification  of  the  subject.     It 
requires  a  master's  hand  to  simplify  in  this  way,  but  once  done,  others 
can  attain  the  mastery.    Everything  in  this  work  bears  on  practice.     The 
author  has  again   revised   the   boot  thoroughly  to  date,  enriching  the 
alread)^  notable  series  of  illustrations  in  black  and  colors,  with  many  new 
engravings  and  plates,  especially  emphasizing  those  showing  the  steps  of 
operations.     In  this  new  edition  every  illustration  is  original. 

DUNGIilSON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCI- 
ENCE. Containing  a  full  explanation  of  the  various  subjects  and 
terms  of  Anatomy,  Physiology,  Medical  Chemistry,  Pharmacy,  Phar- 
macology, Therapeutics,  Medicine,  Hygiene,  Dietetics,  Pathology,  Sur- 
gery, Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecol- 
ogy, Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistiy,  etc.,  etc. 
By  ROBLEY  DUNGLISON,  M.  D.,  LL.  D.,  late  Professor  of  Institutes 
of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia.  New 
(23d)  edition,  thoroughly  revised  by  Thomas  L.  Stedman,  M.D., 
In  one  magnificent  imperial  octavo  volume  of  1220  pajjes  with  577 
illustrations,  including  84  full  page  plates  mostly  in  colors.  With 
thumb  letter  index.  Cloth,  $8,  vet;  leather,  $9,  net;  half  Morocco, 
*9..50,  net. 


The  name  of  Dunglison  stands 
forth  as  that  of  the  greatest  medical 
lexicographer  of  the  English 
language.  For  seventy-five  years 
this  work  has  been  the  standard 
dictionary  used  by  the  English- 
speaking  medical  world,  and  now 
in  its  twenty-third  edition  it  is  a 
pleasure  to  realize  that  it  remains 
fully  up  to  the  standard  of  the  met 
modern  requirements.  —  American 
Journal  of  the  Medical  Sciences. 

Di^nglison's  Medical  Dictionary 
remains  what  it  has  always  been, 
the  criterion  of  medical  lexico- 
graphy.— Medical    Review    of    Be- 


The  standard  work  of  its  kind. — 
American  Practitioner  and  News. 

Along  with  Gray's  Anatomy, 
Dunglison's  Dictionary  has  stood 
the  test  of  time  and  practical  value. 
It  stands  at  the  head.— Clinical 
Beriew. 

It  has  held  the  first  place.  Others 
have  appeared  and  vanished.  Dung- 
lison became  an  institution  in 
medicine.  It  is  a  thorough  ex- 
emplar of  twentieth  century  medi- 
cine. Complete,  thorough,  clear. 
Pre-eminent  among  medical  diction- 
aries.— St.  Louis  Medical  emd  Sur- 
gical Journal. 


DUNHA3I  (EDWARD    K.).       MORBID    AND     NORMAL     HIS- 
TOLOGY.    Octavo,  450  pages,with  363  illustrations.  Cloth,  $3.25,  net. 
The  best  one-volume  text  or  refer-  1  of  published  in  America. —  Virginia 
ence  book  on  histology  that  we  know  I  iledical  Sem.i-3Ionthly. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.       9 

DUNHAM  (EDWARD  K.)  NORMAL  HISTOLOGY.    New  (3rd)  and 

revised    edition.    Octavo,  334  pages,  with  260  illustrations.     Cloth, 
$2.75,  net.     Just  ready.     A  notice  of  the  previous  edition  is  appended. 


This  is  a  splendid  work,  clear  and 
succinct,  but  at  the  same  time  ex- 
haustive enousrh  to   meet  the   de- 


mands of  the  day.     The  illustrations 
are  up-to-date  in  every  particular. — 

American  Practitioner  and  News. 


DWIGHT  (EDWIN   WEIiliES).     AN   EPITOME    OF   MEDICAL 

.JUEiSPRUDENCE.     12mo,   240  pages.     Cloth,   $1  net.    See  Lea's 
Series  of  Medical  Epitomes,  page    18. 

AN  EPITOME  OF  TOXICOLOGY.     See  Lea's  Series  of  Medical 

Epitomes,  paste  18. 

ECKLEY  (WILLIAM  T.).  A  GUIDE  TO  DISSECTION  OF  THE 
HUMAN  BODY.  Octavo,  400  pages,  220  illustrations  in  black  and 
colors.     Cloth,  $3.50  7iet. 


and  the  text  plain  and  concise.  We 
regard  it  as  a  most  excellent  book. 
Nashville  Journal  of  Medicine  and 
Surgery. 


An  exceedingly  useful  hand-book 
for  the  student,  prepared  to  be  used 
in  connection  with  the  most  popular 
text-books  of  the  day.  Gray  and 
Gerrish.     The  arrangement  is  good 

EOKLEY    (WILLIAM    T.).      REGIONAL    ANATOMY    OF   THE 
HEAD  AND  NECK.      Octavo,  2-10  pages,  with  36  engravings  and 
20  plates  in  black  and  colors.     Cloth,  $2.50,  net. 
A  most  excellent  work  of  especial  i  that  chapter.     The  engravings,  and 


especially  the  colored  plates,  are 
fine  and  if  the  student  cannot  get  a 
correct  understanding  from  their 
study  it  must  certainly  be  his  own 
fault. — The  Dental  Summary. 


interest  to  the  dentist.  It  is  seldom 
one  sees  a  book  so  well  arranged  and 
so  concisely  written  as  this  one.  At 
the  end  of  each  chapter  quiz  ques- 
tions are  given  covering  the  text  in 

EDES  (ROBERT  T.).  TEXT-BOOK  OF  THERAPEUTICS  AND 
MATERIA  MEDICA.  In  one  8vo.  volume  of  544  pages.  Cloth,  $3.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for 
Students  and  Practitioners.  In  one  handsome  8vo.  volume  of  576  pages, 
with  148  engravings.    Cloth,  $3. 

EGBERT  (SENECA).    A    MANUAL   OF  HYGIENE  AND  SANI- 
TATION.    New  (3rd)  and  revised  edition.     In   one    12mo.  volume 
of  467  pages,  with  86    illustrations.     Cloth,  $2.25,  net. 
A  concise,  comprehensive  manual,  i  lay  reader.     It  deals  with  personal 

alike  suitable  for  the  medical  stu-    hygiene  as  well  as  public  health.— 

dent,  sanitary  inspector  aod  for  the  I  The  Sanitarian. 

ELLIS  (GEORGE  VEVER).  DEMONSTRATIONS  IN  ANATOMY. 
Eighth  edition.  Octavo,  716  pages,  with  249  engravings.  Cloth, 
$4.25 ;  leather,  $5.25. 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  GYNECOLOGY.  Third  edition.  Octavo,  880  pages,  with 
150  original  engravings.     Cloth,  .|5 ;  leather,  $6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SUR- 
GERY. Eighth  edition.  In  two  large  octavo  volumes  containing 
2316  pages,  with  984  engravings.     Cloth,  $9 ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  &ee  American 
Text-Books  of  Dentistry,  page  2. 

ESSIG  (CHARLES  J.)  and  KOENIG  (AUGUSTUS).  DENTAL 
METALLURGY.  New  (5tli)  edilioii,  thoroughly  revised.  12mo, 
318  pages,  76  engravings.     Cloth,  ^2.0U, /(c^.     Just   ready. 


10     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

EVANS  (DAVID  J.).  A  POCKET  TEXT-BOOK  OF  OBSTETRICS, 
in  one  handsome  12rao.  volume  of  409  pages,  with  148  illustrations. 
Cloth,  $1.75,  net;  limp  leather,  $2.25,  net.  Lea's  Series  of  Pocket 
Text-books,  edited  by  Bern  B.  Gallaudet,  M.D.  See  page  18. 


Written  for  the  medical  student 
and  practitioner  by  one  whose  ex- 
perience, both  clinical  and  teaching, 
has  specially  fitted  him  for  the  task. 


It  is  compendious,  concise  and  readi- 
ly intelligible,  giving  the  essentials 
of  its  subject  in  its  most  modern 
aspect. — Indiana  Medical  Journal. 


E WING  (JAMES).     CLINICAL  PATHOLOGY  OF  THE  BLOOD.   A 

Treatise  on   the    General    Principles    and    Special  Applications  of 

Hematology.      New  (2d)   edition,   thoroughly    revised.      Handsome 

octavo,  492  pages,  43  engravings,  18  colored  plates.     Cloth,  $3.50,  net. 

In  all  of  those  medical  colleges  in  I  certainly  made  it  a  reliable  guide 

which  hematology  is  taught  the  book  i  for  all  those  who  desire  to  enter  up- 

before  us  has  been  recommended  for    on  the  work  of  blood  examination. 

a  text-book,  and  no  better  one  could  I  — St    Louis   Medical   and  Surgical 

have  been  chosen.    The  author  has  |  Journal. 

EXAMINATION  SERIES  (STATE  BOARD).  See  page  26. 

FARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Fourth  American  from  fourth  English  edition,  revised  by  Frank 
Woodbury,  M.  D.    In  one  12mo.  volume  of  581  pages.    Cloth,  $2.50. 

FERGUSON  (J.  B ).  AN  EPITOME  OF  NOSE  AND  THROAT 
DISEASES.     See  Lea's  Series  of  Medical  Epitomes,  page  18. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE 
EAR.  Fourth  edition.  In  one  octavo  volume  of  391  pages,  with  73 
engravings  and  21  colored  plates.      Cloth,  $3.75. 

FINDLEY   (PALMER   D.).       A  TREATISE  ON   GYNECOLOGI- 
CAL  DIAGNOSIS.     Octavo,  493  pages,  210  engravings,  45  plates, 
'dack  and  colors.     Cloth,  $4.50;  leather,  $5.50,  ?ie«. 


This  elaborate  work  will  occupy 
a  unique  place  in  gynecological 
literature  inasmuch  as  it  is  the  first 
on  the  subject  in  the  English 
language.  lit  is  adapted  to  the  needs 
of   both  student  and    practitioner, 


and  will  be  found  of  the  greatest 
value  to  both.  It  is  thoroughly  illus- 
trated with  excellent  cuts  and 
colored  engravings.  The  text  is  full 
and  plain  — Nashville  Journal  of 
Medicine  and  Surgerij. 


FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Seventh  edition,  thoroughly  revised 
by  Frederick  P.  Henry,  M.  D.  In  one  large  8vo.  volume  of  1143 
pages,  with  engravings.     Cloth.  $5.00 ;  leather,  $6.00. 

FLINT  (AUSTIN).  A  PRACTICAL  TREATISE  ON  THE  DIAG- 
NOSIS AND  TREATMENT  OF  DISEASES  OF  THE  HEART. 
Second  edition  enlarged.   In  one  octavo  volume  of  550  pages.    Cloth,  $4. 

ON  PHTHISIS :  ITS  MORBID  ANATOMY,  ETIOLOGY,  ETC. 

A  Series  of  Clinical  Lectures.      8vo.  442  pages.     Cloth,  $3.50. 
-ESSAYS  ON  CONSERVATIVE  MEDICINE  AND  KINDRED 


TOPICS.     12mo,  214  pages.     Cloth,  $1.38. 
FORMULARY,  POCKET.  See  page  32. 

POSTER  (MICHAEL).    A  TEXT-BOOK  OF  PHYSIOLOGY.    Sixth 

and  revised  American  from  the  sixth  English  edition.     In  one  large 

octavo  volume  of  923  pp.,  with  257  illus.     Cloth,  $4.50 ;  leather,  $5.50. 

Unquestionably  the  best  book  that  I  busy  physician  it  can   scarcely  be 

can  be  placed  in  the  student's  hands,    excelled. — The  Phila.  Polyclinic. 

and  as  a  work  of  reference  for  the 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     11 

FOTHERGILIj  (J.  MLLNER).  THE  PRACTITIONER'S  HAND- 
BOOK OF  TREATMENT.  Third  edition.  In  one  handsome  octavo 
volume  of  664  pages.     Cloth,  $3.75  ;  leather,  $4.75. 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEM- 
ISTRY (INORGANIC  AND  ORGANIC).  Twelfth  edition.  Em- 
bodying Watts'  Physical  and  Inorganic  Chemistry.  12mo.,  1061 
pages,  168  engravings,  and  1  colored  plate.    Cloth,  $2.75  ;  leather,  $3.25. 

FRANKXiAND  (E.)  AND  JAPP  (F.  R.).  INORGANIC  CHEMISTRY, 
In  one  handsome  octavo  volume  of  677  pages,  with  51  engravings  and 
2  plates.     Cloth,  $3.75 ;  leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  OR- 
GANS IN  THE  MALE.  In  one  very  handsome  octavo  volume  of 
238  pages,  with   25  engravings  and  8  full-page  plates.      Cloth,  $2. 

GALLiAUDET  (BERN  B.).  A  POCKET  TEXT-BOOK  ON  SUR- 
GERY. In  one  handsome  12mo.  volume  of  about  400  pages,  with  many 
illustrations.    Shortly.    See  Lea's  Series  of  Pocket  Text-books,  page  18. 

GANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  _  A 
Multum  in  Parvo.  In  one  square  octavo  volume  of  845  pages,  with 
159  engravings.     Cloth,  $3.75. 

GAYLORD  (HARVEY  R.)  and  ASCHOFF  (LUDWIG).    THE 
PRINCIPLES  OF  PATHOLOGICAL  HISTOLOGY.    With  an  in- 
troductory note  by  William  H.  Welch,  M.  D.    Quarto,  354  pages, 
with  81  engravings  and  40  full-page  plates.     Cloth,  $7.50,  nei. 
Admirably  arranged  and  beauti-  j  tion  of  a  work  which  should  be  in 

fully  illustrated.    The  authors  are  j  the  hands  of  every  student  of  morbid 

to  be  congratulated  on  the  produc-  '  histology. — Londoji  Practitioner. 

GERRISH  (FREDERIC  H.).  A  TEXT-BOOK  OF  ANATOMY. 
By  American  Authors.  Edited  by  Frederic  H.  Gerrish,  M.  D.  Second 
and  revised  edition.  In  one  imperial  octavo  volume  of  937  pages, 
with  1003  illustrations  in  black  and  colors.  Cloth,  $6.50,  iiet.  leather, 
$7.50,  net;  half  Morocco,  $8.00,  ?(<■/;. 
The  illustrations  far  outnumber       The  text  is  accurate,  concise,  and 

and  exceed  in  size  and  in  profusion  \  gives  the    essentials   of  descriptive 


of  colors  those  in  any  previous  work  ; 
and  they  can  well  claim  to  be  the 
most  successful  series  of  anatomical 
pictures  in  the  world. — The  Ameri- 
can Practitioner  and  News. 


anatomy  with  less  waste  of  words  and 
better  emphasis  of  important  points 
than  any  similar  text-book  with 
which  we  are  familiar. — The  Boston 
Medical  and  Surgical  Journal. 


GIBBES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID 
HISTOLOGY.   Octavo,  314  pages,  with  60  illustrations.    Cloth,  $2.75. 
GRAY    (HENRY).      ANATOMY,   DESCRIPTIVE    AND    SURGI- 
CAL.    New  (fifteenth)  edition  thoroughly  revised.     In  one  imperial 
octavo  volume  of  1249  pages,  with  780  large  and  elaborate  engrav- 
ings.    Price  with  illustrations  in  colors,  cloth,  %Q.25,  net ;  leather, 
$7.25,   net.      Price,    with    illustrations    in    black,    cloth,    $5.50,  net; 
leather,$6.50,  net. 
This   is    the  best  single  volume  I  so  indefinitely.     No  book  will  ever 
upon    Anatomy     in     the     English    take  its  place  liefore  the  Examining 
language. —  University  Medical  Mag-    Boards  of  this  country — it  will   be 
azine.  \  their     standard. — The       America?/, 

Holds  first  place  in  the  esteem  of :  Practitioner  and  News. 


both    teachers    and    students. — The 
Brooklyn  Medical  Journal. 

Without  a  doubt  tlie  most  com- 
plete work  on  anatomy  published 
in  the  English  language,  dray  atiW 
remains  the  text-book  of  all  medical 
students,  and  will  doubtless  remain 


The  most  largely  used  anatomical 
text-book  published  in  the  English 
language. — Annals  of  Surgery. 

Gray's  Anatomy  affords  the  student 
more  satisfaction  than  any  other 
treatise  with  which  we  are  familiar. 
— Bvffalo  3Ted.  Journal. 


12      Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

GRAYSON    (CHARLES    P.).      DISEASES    OF   THE   THROAT, 

NOSE,  AND  ASSOCIATED  AFFECTIONS  OF  THE  EAR.  In 
one  handsome  octavo  volume  of  548  pages,  with  129  engravings  and 
8  plates  in  colors  and  monochrome.     Cloth,  $3.50,  net. 

It  is  a  practical  book,  telling  j  and  it  is  proportionately  valuable. 
"  not  only  what  to  do,  but  how  to  do  \  The  book  is  well  written  and  is  a 
it."  Under  "Treatment,"  the  author  ■  serviceable  and  practical  addition  to 
is  very  evidently  and  sincerely  giv-  I  the  literature  of  the  subjects  treated, 
ing,  not  compilations  from  other  ■  — Medical  Record. 
men's  work,  but  his  own  experiences,  I 

GREEN  (T.HENRY).    PATHOLOGY  AND  MORBID  ANATOMY. 

Ninth  edition.  In  one  handsome  octavo  volume  of  577  pages,  with 
339  engravings  and  4  colored  plates.     Cloth,  $3.25,  net. 

The  work  is  an  essential  to  the 


practitioner — whether  as  surgeon  or 
physician.     It  is  the  best  of  up-to- 


date  text-books. —  Virginia  3Iedical 
Monthly. 


GREENE  (WnLiLLAM  H.).  A  MANUAL  OF  MEDICAL  CHEM- 
ISTRY. For  the  Use  of  Students.  Based  upon  Bowman's  Medical 
Chemistry.    In  one  12mo.  vol.  of  310  pages,  with  74  illus.   Cloth,  $1.75. 

GRINDON    (JOSEPH).      A    POCKET    TEXT-BOOK    OF     SKIN 

DISEASES.     In  one  handsome  12mo.  volume  of  367  pages,  with  39 

illustrations.       Cloth,  $2.00.  ^e^;   flexible  leather,  $2.50,  net.      See 

Zea's  Series  of  Pocket  Text-books,  page  18. 

A  compendious  and   trustworthy  !  tology.    As  a  therapeutic  adviser  for 

guide  book  for  the  practitioner  as    the  doctor  it  is  replete  with  direc- 

well    as    student,    embodying    the  j  tions  and   valuable  formulte. — The 

most  recent  developments  in  derma-  [  Virginia  Medical  Semi-Monthly. 

GROSS  (SAMUEL,  D.).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES, INJURIES  AND  MALFORMATIONS  OF  THE  URINARY 
BLADDER,  THE  PROSTATE  GLAND  AND  THE  URETHRA. 
Third  edition.    Octavo,  574  pages,  with  170  illustrations    Cloth,  $4.50. 

GUENTHER(A.  E.  AND  T.  C).  AN  EPITOME  OF  PHYSIOLOGY. 
12mo,  225  pages,  illustrated.  Cloth,  $1.00,  net.  Lea's  Series  of  Medi- 
cal Epitomes.     See  page  18. 

HABERSHON  (S.  O.).  DISEASES  OF  THE  ABDOMEN.  Second 
American  from  the  third  English  edition.  Octavo,  554  pages,  with 
11  engravings.    Cloth,  $3.50. 

HALiE  (HENRY  E.).  AN  EPITOME  OF  ANATOMY.  12mo., 
389  pages,  71  engravings.  Cloth,  $1.00,  net.  See  Lea's  Scries  of 
Medical  Epitomes,  page  18. 

HALL,  (WINFIELD  S.).  TEXT-BOOK  OF  PHYSIOLOGY.  Octavo 
of  672  pages,  with  343  engravings,  and  6  full  page  colored  plates. 
Cloth,  $4.00,  net  ;   leather,  $5.00,  net. 

Students  and  teachers  may   pur-  The    clearness    with    which 

chase  the  work  with  the  certainty  physiological  facts  are  demonstrated 

that  they  will  ol>tain  a  thoroughly  makes  it    of   special   value  to  the 

sound  and  reliable  exposition  of  the  medical  student.     Western  3Iedical 

present  state  of  physiological  know-  Revieiv. 
ledge. — The  London  Lancet. 


Lea  Bkothees  &  Co.,  Philadelphia  and  New  Yoek.     13 


HAMILTON  (ALLAN  MCLANE).  NERVOUS  DISEASES,  THEIR 
DESCRIPTION  AND  TREATMENT.  Second  and  revised  edition. 
In  one  octavo  volume  of  598  pages,  with  72  engravings.     Cloth,  $4. 

HAMILTON  (MILDRKD).  A  POCKET  TEXT- BOOK  OF  MAS- 
SACRE.    Prepdring.     See   Lcr/'.s-  Srrirs  of  Pocket  Tc.vt-Hool:<i,  page  IS. 

HARDAWAY(W.A.).     MANUAL  OF  SKIN  DISEASES.     Second 
edition.   In  one  12mo.  volume  of  560  pages,  with  40  illustrations  and 
2  plates.     Cloth,  $2.25,  net. 
The  best  of  all  the  small  books  to  j  day  clinical  experience.    His  great 
recommend  to  students  and  practi-  j  strength  is  in  diagnosis, descriptions 
tioners.     Probably   no  one    of   our  j  of  lesions  and   especially   in  treat- 
dermatologists  has  had  a  wider  every-  !  ment. — Indiana  lledieal  Journal. 

HARE  (HOBART  AMORY).     PRACTICAL    DIAGNOSIS.    THE 
USE  OF  SYMPTOMS  IN  THE  DIAGNOSIS  OF  DISEASE.     Fifth 
edition.     In  one  octavo  volume  of  692  pages,  with  240  engravings 
and  25  full-page  colored   plates.     Cloth,  $5.00,  ?ie(;    leather,  $6.00, 
net;   half  Morocco,  $6.50,  weZ. 
Dr.  Hare  is  eminently  practical,  '  physical  signs    and    clinical   tests, 
he  appreciates  the  needs  of  the  gen-  i  Tliis  makes  the  treatise  a  complete 
eral  practitioner  ;  and  in  presenting    guide  for  the  purposes  of  diagnosis, 
the  symptoms  as  met  at  the  l)e<1side    The  chemical  and  microscopical  ex- 
and  discussing  disease  as  it  actually    amiuation  of  the  blood  is  described 
appears,  he  has  no  peer.     The  new    in  detail.     Directions  as  to  urinary 
edition  has  been   carefully  revised,    diagnosis  are  concise  and  complete, 
and  its  scope  has  been  widened  to  in-    — St.  Louis  Courier  of  Medicine. 
elude  not  only  symptoms  but  also 

HARE  (HOBART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL 
THERAPEUTICS,  with  Special  Reference  to  the  Application  of  Reme- 
dial Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  With  articles  on  various  subjects  by  well-known  specialists. 
Ninth  and  revised  edition.  In  one  octavo  volume  of  851  pages, 
with  105  engravings  and  4  colored  plates.  Cloth,  $4.00,  net;  leather, 
$5.00,  net;   half  Morocco,  $5.50,  net. 


.Tust  the  book  the  active  physician 
most  needs.  He  generally  needs 
the  information  he  seeks  quickly, 
too,  and  here  he  finds  it,  accessible, 
clear  and  adecjuate.  On  every 
occasion  we  have  consulted  its  pages, 
and  taey  are  many,  we  have  never 
turned  away  in  disappointment. 
This  must  continue  to  be  //ic  text- 
book, par  excellence,  of  therapeutics. 
■ — Buffalo  Medical  Journal. 

We  know  of  no  book  which  is  its 
equal  in  practical  therapeutics. — 
Boston  Medical  and  Surgical  .Jour 
nal. 

The  great  value  of  the  work  lies 
in  the  fact  that  precise  indications 


for  administration  are  given.  A 
complete  index  of  diseases  and 
remedies  makes  it  an  easy  reference 
work.  It  has  been  arranged  so  that 
it  can  be  readily  used  in  connection 
with  Hare's  Practical  Diagnosis. 
For  the  needs  of  the  student  and 
general  practitioner  it  has  no  equal. 
— Medical  Sentinel. 

The  best  planned  therapeutic  work 
of  the  century. — Americayi  Prac- 
titioner and  News. 

It  is  a  book  precisely  adapted  to 
the  needs  of  the  busy  practitioner, 
who  can  rely  upon  finding  exactly 
what  he  needs.— y^e  National  Med- 
ical Revi&w. 


HARE  (HOBART  AMORY)     ON  THE   MEDICAL   COMPLICA- 
TIONS AND    SEQUELAE  OF  TYPHOID   FEVER.      Octavo,  276 
pages,  21  engravings  and  two  full-page  plates.     Cloth,  $2.40,  net. 
A  very  valuable  production.    One  l  read  with  great  profit. — Cleveland 

of  the   very    best    products   of    Dr.  |  Journal  of  Medicine. 

Hare  and  one  that  every  man  can 


14     Lea  Bbothees  &  Co.,  Philadelphia  and  New  Yoek. 


HARE'S  SYSTEM  OF  PEACTICAL  THEEAPEUTICS.  In  a  series 
of  contributions  by  eminent  practitioners.  Second  edition.  In  three 
large  octavo  volumes  containing  2593  pages,  with  457  engravings 
and  26  full-page  plates.  Price  per  volume,  cloth,  $5.00 ;  leather, 
$6.00;  half  morocco,  $7.00.  Full  prospectus  free  on  application. 
For  sale  by  subscription  only. 


The  System  is  one  of  the  most  im 
portant  additions  a  busy  physician 
can  make  to  the  working  literature 
of    his    library. — Buffalo     Medical 
Journal. 

The  volumes  are  practical.  They 
reflect  the  editor's  ajopreciation  of 
modern  medicine.  The  third  vol- 
ume is  given  up  to  surgery  and  the 
specialties,  and  this  makes  the  set 
suitable  for  the  general  practitioner. 
— The  Boston  Medical  and  Surgical 
Journal. 

The    dominant    feature    of    the 


work,  one  that  the  well-known 
editor  constantly  presents,  is  the 
every- day  workability  of  treat- 
ments advocated.  Here  are  no 
lengthy  theoretical  dissertations 
largely  padded  by  quotations  from 
European  authors,  but  concise,  prac- 
tical rules  that  can  be  made  to  fit 
present-day  needs.  What,  why 
and  HOW  are  the  questions  with  ref- 
erence to  the  use  of  drugs  that  the 
authors  answer  —  particularly  the 
novf  .—Medical  Neiva. 


HARRINGTON  (CHARLES).     PRACTICAL  HYGIENE.     Second 
edition.     Handsome   octavo,   755  pages,   113   engravings,  12  i^lates. 

Net,  $4.25. 


This  l)ook  is  by  far  the  best  work- 
ing manual  of  practical  hygiene  that 
has  yet  appeared  in  the  English 
language.  The  subject  is  handled 
exceedingly  well,  and  shows  that  its 
author  is  a  practical  hj'^gienist,  and 


at  the  same  time  is  perfectly  familiar 
with  allied  branches,  which  are  so 
necessary  for  a  full  comprehension 
of  the  broad  subject  treated.  It  is 
thoroughly  up  to  date. — Interstate 
Medical  Journal. 


HARTSHORNE  (HENRY).  A  CONSPECTUS  OF  THE  MEDI- 
CAL SCIENCES.  Comprising  Manuals  of  Anatomy,  Physiology, 
Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Ob- 
stetrics. Second  edition.  In  one  royal  12mo.  vol.  of  1028  pages,  with 
477  illus.     Cloth,  $4.25 ;  leather,  $5. 

HAYDEN  (JAMES  R.).  A  POCKET  TEXT-BOOK  OF  VENER- 
EAL DISEASES.  Third  edition.  In  one  12mo.  volume  of  304 
pages,  with  66  engravings.  Cloth,  $1.75,  7iet.  Flexible  leather, 
$2.25,  nei.     See  Lea's  Series  of  Pocket  Text-Books,  page  18. 

The  volume  is  practical,  concise,  i  it  is  particularly  thorough. — Pacific 
definite  and  satisfactorily  full.     In    Medical  Journal. 
matters  of  diagnosis  and  treatment  I 

HAYEM  (GEORGES)  AND   HARE  (H.  A.).     PHYSICAL  AND 

NATURAL  THERAPEUTICS.  The  Remedial  Use  of  Heat,  Elec- 
tricity, Modifications  of  Atmospheric  Pressure,  Climates  and  Mineral 
Waters.  Edited  by  Prof.  H.  A.  Hare,  M.D.  In  one  octavo  volume 
of  414  pages.with  113  engravings.     Cloth,  $3. 

HERMAN  (G.  ERNEST).  FIRST  LINES  IN  MIDWIFERY.  In 
one  12mo.  vol.  of  198  pages,  with  80  engravings.  Cloth,  $1.25.  See 
Student's  Series  of  Manuals,  page  27. 

HERMANN  (Ij.).  EXPERIMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  Robert  Meade  Smith,  M.  D.  In  one  12mo. 
Tolume  oi  199  pages,  with  32  engravings.     Cloth,  $1.50. 


Lba  Beothkbs  &  Co.,  Philadelphia  and  New  Yobk,     15 


HERRICK  (JAMES  B.).  A  HANDBOOK  OF  DIAGNOSIS.  In 
one  handsome  12mo.  volume  of  429  pages,  with  80  engravings  and  2 
colored  plates.     Cloth,  $2.50. 


We  commend  the  book  not  only  to 
the  undergraduate,  but  also  to  the 
physician  who  desires  a  ready  means 
of  refreshing  his  knowledge  of  diag- 
nosis in  the  exigencies  of  professional 
life. — Memphis  3fedical  Monthly. 


Excellently  arranged,  practical, 
concise,  up-to-date,  and  eminently 
well  fitted  for  the  use  of  the  prac- 
titioner as  well  as  of  the  student. — 
Chicago  Med.  Recorder. 


HERTER    (O.   A.).     LECTUEES  ON  CHEMICAL  PATHOLOGY. 

In  one  12mo.,  volume  of  454  pages.     Cloth,  $1.75,  net. 


The  lectures  are  eminently  prac- 
tical. A  great  variety  of  subjects 
is  dealt  with  in  a  most  attractive 
manner.  The  volume  is  not  a  de- 
scription of  the  normal  physiological 
processes  going  on  in  the  healthy 


body,  but  rather  an  account  of  the 
altered  chemical  changes  which  take 
place  in  the  different  organs  and  se- 
cretions in  various  diseases.  The 
book  is  full  of  interesting,  practical 
points. — Johns  Hopkins  Bxdletin. 


HELL  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDERS.     In  one  8vo.  volume  of  479  pages.     Cloth,  $3.25. 

HIL.LIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES. 
Second  edition.  In  one  royal  12mo.  volume  of  353  pages,  with  two 
plates.     Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PEERSOL.  (GEORGE  A.).  HUMAN 
MONSTROSITIES.  Magnificent  folio,  containing  220  pages  of  text 
and  illustrated  with  123  engravings  and  39  large  photographic  plates 
from  nature.  In  four  parts,  price  each,  $5. 

HOBLYN  (RICHARD  D.).  A  DICTIONARY  OF  THE  TERMS 
USED  IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
Thirteenth  edition.  In  one  12mo.  volume  of  845  pages.  Cloth, 
$3.00,  net. 

This  is  a  volume  of  almo.st  900  I  that  it  has  gone  through  12  editions 
pages,  printed  in  easily-read  type,  is  an  evidence  that  the  medical  pro- 
and  is  fullj^  up  to  date,  embracing,  fession  has  found  it  meets  their 
practically  all  the  terms.     The  fact  |  wants. — Canada  Medical  Record. 

HOIiLTS  (A."W.).  AN  EPITOME  OF  MEDICAL  DIAGNOSIS.     See 

Lea\s  Scries  of  Medical  Epitomes,  page  18. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Prin- 
ciples and  Practice.  Fifth  edition.  Edited  by  T.Pickering  Pick, 
F.R.C.S.  In  one  handsome  octavo  volume  of  1008  pages,  with  428  en- 
gravings.    Cloth,  $6.00;  leather,  $7. <  10. 


HOLMES  (TIMOTHY).  A  SYSTEM  OF  SURGERY.  With  notes  and 
additions  by  various  American  authors.  Edited  by  John  H.  Packard, 
M.D.  In  three  8vo.  volumes  containing  3137  pages,  with  979  engravings 
and  13  platea.     Per  volume,  cloth,  $6.0(J ;  leather,  $7.00. 


l6     Lea  Beothers  <&  Co.,  Philadelphia  and  New  York, 


HUNTINGTON  (GKORGE  S.).  A  TREATISE  ON  ABDOMINAL 
ANATOMY.  Quarto,  590  pages  including  300  full-page  plates  in 
black  and  colors,  containing  582  figures.  De  luxe  binding,  $10,  net. 
The  mysteries  of  the  Peritoneum  and  Abdominal  Cavity  particularly 
concern  auatomists,  surgeons,  gynecologists  and  obstetricians,  and  in- 
terest the  s^eneral  practitioner  to  a  degree  scarcely  less.  This  compre- 
hensive and  authoritative  work  will  therefore  appeal  to  an  unusually 
wide  constituency  of  readers.  Dr.  Huntington  has  approached  the  sub- 
ject in  the  liglit  thrown  upon  it  by  embryologj"  and  comparative  anatomy, 
thereby  clarifying  the  hitherto  ditticult  and  complicated  moriihological 
problems  presented  by  these  regions.  The  l)pok  is  unique  in  its  marvelous 
wealth  of  illustrations,  amounting  practically  to  an  Atlas,  with  full  ex- 
planatory text.  The  structural  details  of  the  Human  Csecum  and 
Appendix  are  considered  very  fully  by  reason  of  the  extensive  material 
available  and  the  paramount  clinical   importance  of  these  subjects. 

HYDE  (JAMES  NEVINS)  AND  MONTGOMERY  (F.  H.)  A 
PRACTICAL  TREATISE  ON  DISEASES  OF  THE  SKIN.  Sixth 
edition,  thoroughly  revised.  Octavo,  832  pages,  with  107  engrav- 
ings and  27  full-page  plates,  9  of  which  are  colored.  Cloth,  $4.50,  net; 
leather,  $5.50,  net;  half  Morocco,  $6.00,  net. 


This  is  beyond  doubt  the  most 
successful  work  on  skin  diseases. 
This  work  is  now  looked  upon  as 
the  American  authority. — »S^  Louis 
Medical  and  Surgical  .Journal. 

The  first  American  text-book. — 
Northwestern  Lancet. 

The  work  answers  the  needs  of  the 
general  practitioner,  the  specialist, 
and  the  student. — The  Ohio  Med- 
ical Journal. 

A  treatise  of  exceptional  merit 
characterized  by  conscientious  care 
and  scientific  accuracy.  —  Buffalo 
Medical  a^id  Surgical  Journcd. 


A  complete  exposition  of  our 
knowledge  of  cutaneous  medicine  as 
it  exists  to-day.  The  teaching  in- 
culcated throughout  is  sound  as  well 
as  practical. —  The  American  Jour- 
nal of  the  iledical  Sciences. 

It  is  the  best  one-volume  work 
that  we  know. —  Virginia  Medical 
Semi-Mo7ithly. 

A  full  and  thoroughly  modern 
text-book  on  dermatology.  —  The 
Pittsburg  Medical  Review. 

The  most  practical  handbook  on 
dermatology  with  which  we  are  ac- 
quainted.—  Chicago  Med.  Recorder. 


JACKSON  (GEORGE  THOMAS).  THE  READY-REFERENCE 
HANDBOOK  OF  DISEASES  OF  THE  SKIN.  Fourth  edition. 
In  one  12mo.  volume  of  617  pages,  with  82  illustrations  and  3  colored 
plates.    Cloth,  $2.75,  net. 


The  work  is  especially  rich  in 
formulte  and  practical  methods  of 
treatment. — Medicine. 


"Without  doubt  forms  one  of  the 
best  guides  for  the  beginner  in  der- 
matology that  is  to  be  found  in  tlie 
English  language. — Medicine. 

JAMIESON  (W.  ALiLfAN).  DISEASES  OF  THE  SKIN.  Third 
edition.  In  one  octavo  volume  of  656  pages,  with  1  engraving  and  9 
double-page  chromo-lithographic  plates.    Cloth,  $6. 


JEWETT    (CHARLES).      THE 

By  American  Authors.     Sceond 
445    engravings    in   black    and 
plates.  Cloth,  $5.00,  net ;  leather. 
The  most  complete  of  the  recent 
obstetric  text-books     The  illustra- 
tions are  superb  and  possess  the  merit 
of  clearness  and  accuracy. — Buffalo 
Medical  and  Surgiccd-  Journal. 

It  is  pre-eminently  a  practical 
treatise  suited  to  the  needs  of  medical 
classes,  while,  at  the  same  time,  it 


PRACTICE    OF   OBSTETRICS. 

edition.  Octavo,  775  pages,  with 
colors,  and  35  full-page  colored 
$6.00,  net;  half  Morocco,  $6.50,  net. 
furnishes  a  concise,  comprehensive 
and  trustworthy  guide  to  the  prac- 
titioner. We  regard  this  as  being 
one  of  the  most  scientific  and 
thoroughly  modern  treatises  upon 
this  important  subject  in  use  to-day. 
— Anier.  Gynecological  and  Obstet- 
rical Journal. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     17 


JEWETT   (CHARLES).  ESSENTIALS  OF  OBSTETRICS.    Second 
edition.     In  one  12mo.  volume  of  385  pages,  with  80  engravings  and 
5  colored  plates.     Cloth,  $2.25,  net. 
This  is  the  best  epitome  of  obstet- 1  students  and  practitioners  and  to  lec- 


rics  with  which  we  are  familiar.  It 
is  sutticiently  illustrated  to  make 
clear  its  text.  Its  contents  are  well 
selected.    It  can  be  recommended  to 


turers  who  need  to  review  salient 
points  of  al)Stetrics  in  preparing  their 
instruction. — I'kc  Ajnrrican  JournnI 
of  the  JMrdicnl  Scieiice-'i. 

JUL.ER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 
AND  PRACTICE.  New  (3rd)  edition.  In  one  octavo  volume  of  733  pp., 
with  190  engravings,  25  chromo-lithographic  plates.    Cloth,  $5.25,  net. 

KELliY  (A.  O.  J.).  A  MANUAL  OF  THE  PRACTICE  OF  MEDI- 
CINE.    Octavo,  about  600  p'Jges,  illustrated.     Preparing. 

KIEPE  (EDWARD  J.).  AN  EPITOME  OF  MATERIA  MEDICA 
AND  THERAPEUTICS.  See  Lea's  Series  of  Medical  Epitomes,  p.  18. 

KING  (A.  P.  A.).  A  MANUAL  OF  OBSTETRICS.  New  (9th)  edition.  In 
one  12mo.  volume  of  629  pages,  with  275  illustrations.    Cloth,  $2.50,  net. 


The  best  manual  that  has  ever  been 
offered  to  us.  It  has  a  wonderful 
fund  of  information  in  a  very  small 
space. — jY.  O.  Med.  and  Snrg,  Jour. 


The  most  succinct,  reliable  and  at 
the  same  time  individual  book  for  a 
student  or  practitioner. — Medical 
Xews. 


KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  See  Ameri- 
can Text-Books  of  Dentistry,  page  2. 

KLEIN   (E.).      ELEMENTS    OF  HISTOLOGY.     Fifth  edition.     In 
one  12mo.  volume  of  506  pages,  with  296  engravings.     Cloth,  $2.00, 
net.     See  Student's  Series  of  Manuals,  page  27. 
It  is  the  most  complete  and  con- 1      This  work  deservedly  occupies  a 

cise  work  of  the  kind  that  has  yet    first  place  as  a  text- book  on   his- 

emanated  from  the  press. — Med.  Age.  1  tology. —  Canadian  Practitioner. 

KOPLIK  (HENRY).  THE  DISEASES  OF  INFANCY  AND 
CHILDHOOD.  Octavo,  675  pages  with  169  engravings,  and  32 
plates  in  black  and  colors.     Cloth,  $5.00,  net ;   leather,  $6.00,  net. 


Certainly  the  best  book  for  stu- 
dents we  have  seen  for  some  time,  as 
it  is  clear,  concise,  epigrammatic  and 
certain  to  make  an  impression  on 
the  mind  of  the  reader.  It  is  fully 
up  to  date.    We  are  specially  pleased 


with  the  treatment,  which  is  not 
complex,  but  simple  and  positive, 
with  proper  regard  to  dosage,  so 
often  neglected  in  books  of  this  kind, 
to  the  detriment  of  the  student. — 
Chicago  Medical  Record. 


LANDIS  (HENRY  G.).   THE  MANAGEMENT  OF  LABOR.   In  one 

handsome  12mo.  volume  of  329  pages,  with  28  illus.   Cloth,  $1.75. 

LEA  (HENRY  C).  A  HISTORY  OF  AURICULAR  CONFESSION 
AND  INDULGENCES  IN  THE  LATIN  CHURCH.  In  three 
octavo  volumes  of  about  500  pages  each.     Per  volume,  cloth,  $3.00. 

CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF  SPAIN ; 

CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINA- 
TI  OF  THE  ENDEMONIADAS ;  EL  SANTO  NIlJO  DE  LA 
GUARDIA.     12mo.,  522  pages.     Cloth,  $2  50. 

THE  MORISCOS  OF  SPAIN,  THEIR  CONVERSION  AND  EX- 
PULSION. In  one  royal  12mo.  volume  of  425  pages.  Cloth,  $2.25,  net. 

SUPERSTITION   AND   FORCE;  ESSAYS  ON  THE  WAGER 

OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  Fourth  edition,  thoroughly  revised.  In  one  hand- 
some royal  12mo.  volume  of  629  pages.     Cloth,  $2.75. 

STUDIES  IN  CHURCH  HISTORY.    The  Rise  of  the  Temporal 

Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one 
handsome  12mo.  volume  of  605  pages.    Cloth,  $2.50. 


18     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

LEA'S  SERIES  OP  MEDICAL  EPITOMES.  Edited  by  VICTOR 
C.  Pedersen,  M.D.  Covering  the  entire  field  of  medicine  and  sur- 
gery in  twenty-two  convenient  volumes  of  about  250  pages  each, 
amply  illustrated  and  written  by  prominent  teachers  and  specialists. 
Compendious,  authoritative  and  modern.  Following  each  chapter 
is  a  series  of  questions  which  will  be  found  convenient  in  quizzing. 
Price  per  volume,  cloth,  $1, 7iet.  The  following  volumes  are  now  ready: 
Hale's  Anatomy.  Guenthebs'  Physiology.  McGlannan's  Phys- 
ics and  Inorganic  Chemistry.  McGlannan's  Organic  and  Phys- 
iological Chemistry.  Nagel's  Nervous  and  Mental  Diseases. 
Wathen's  Histology.  Archinard's  Bacteriology  and  Microscopy. 
Magee  &  Johnson's  Surgery.  Alling  and  Griffen  on  the  Eye 
and  Ear.  Schmidt's  Genito-Urinary  and  Venereal  Diseases. 
SCHALEK's  Dermatology.  Mantox's  Obstetrics.  Tuley's  Pedi- 
atrics. Dwight's  Jurisprudence.  Dwight's  Toxicology. 
The  following  volumes  are  in  press :  Kiepe's  Materia  Medica  and 
Therapeutics.  Dayton's  Practice  of  Medicine.  Hollis'  Medical 
Diagnosis.  Arneill's  Clinical  Diagnosis  and  Urinalysis.  Sten- 
house's  Pathology.  Ferguson  on  the  Nose  and  Throat.  Pedersen 
and  Parker's  Gynecology. 

LEA'S  SERIEIS  OF  POCKET  TEXT-BOOKS,  edited  b^  Bern 
B.  Gallaudet,  M.  D.  Covering  the  entire  field  of  Medicine  in  a 
series  of  18  very  handsome  12mo.  volumes  of  350-525  pages  each, 
profusely  illustrated.  Compendious,  clear,  trustworthy  and  modern. 
The  following  volumes  are  now  ready  : 

Rockwell's  Anatomy.  Collins  and  Rockvpell's  Physiology. 
Martin  and  Rockwell's  Chemistry  and  Physics.  Nichols  and 
Vale's  Histology  and  Pathology.  Schleip's  Materia  Medica,  Thera- 
peutics, Medical  Latin,  etc.  Malsbary's  Practice  of  Medicine. 
Potts'  Nervous  and  Mental  Diseases.  Hayden's  Venereal  Diseases. 
Grindon's  Dermatology.  Ballenger  and  Wippern's  Diseases  of 
the  Eye,  Ear,  Throat  and  Nose.  Evans'  Obstetrics.  Crockett's 
Gynecology.  Tuttle's  Diseases  of  Children.  Zapffe's  Bacteriology. 
The  following  volumes  are  in  press  :  Collins  and  Davis'  Diagnosis  ; 
Gallatjdet's  Surgery ;  WiCKs'  Nursing  and  Hamilton's  Massage. 
For  prices  and  separate  notices  see  under  various  authors'  names. 

LE  FEVRE  (EGBERT).     A  TEXT-BOOK  OF  PHYSICAL  DIAG- 
NOSIS.    In  one  12mo.  volume  of  450  pages,with  74  engravings  and 
12  plates.     Cloth,  $2.25,  net. 
This  book  will  take  front  rank.  [  tailed  attention,  and  the  same  meth- 
It  is  prepared  by  a  teacher  of  ex- 1  ods  as  applied  to  the  thorax  are  em- 
perience  and  a  clinician  of  accom-    ployed  and  explained  with  the  varia- 
plishment.    Le  Fevre  gives  adequate  j  tions  necessary.     A   number  of  en- 
instruction  upon  all  the  details  of !  gravings  and  X-ray  plates  elucidate 
diagnosis.    The  abdomen  receives  de-  i  the  text. — Buffalo  Medical  Journal. 

LONG   (EH  H.).     A  MANUAL  OF  DENTAL  MATERIA  MEDICA 
AND  THERAPEUTICS.     12mo,  321  pages,  with  6  engravings  and 
18  plates.     Cloth,  $3.fiO,  net. 
The  author's  aim  has  been  to  cover  what  is  essential ;  to  treat  fully  all 
remedies  that  belong  properly  to  the  special  field  of  dental  medicine ;  to 
discuss  Ijrietiy  the  action  and  application  of  the  most  imijortant  general 
remedies,  emphasizing  those  of  which  the  action  may  avail  in  dental  dis- 
eases and  emergencies,  and  to  furnish  matter  for  reference  that  will  cover 
all  ordinary  demands  of  the  dental  student  and  practitioner  as  to  general 
remedies,  their  preparations,  doses  and  uses.    The  value  of  the  work  is 
much   enhanced    by  the    extensive   Index    of   Drugs,   including    every 
drug  of  local  or  general  use  that  the  dentist  may  have  occasion  to  refer 
to.     This  index  is,  in  fact,  a  general  therapeutic  referendum  for  the  den- 
tal jiractitioner. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     19 


LiOOMIS    (ALFRED    Li.)   AND    THOMPSON    (W.    GIL.MAN), 

EDITORS.       A  SYSTEM    OF    PKACTICAL    MEDICINE.      In 

Contributions  by  Various  American  Authors.  In  four  octavo  vol- 
umes of  about  900  pages  each,  fully  illustrated  in  black  and  colors. 
Per  volume,  cloth,  $5.00,  -net;  leather,  $6.00,  net;  half  morocco,  $7.00, 
net.  For  sale  by  subscription  only.  Full  prospectus  free  on  applica- 
tion to  the  Publishers. 

LYMAN  (HENRY  M.).    THE  PRACTICE  OF  MEDICINE.    In  one 

very  handsome  octavo  volume  of  925  pages,  with  170  engravings. 
Cloth,  $4.75 ;  leather,  $5.75. 

McGLANNAN  (A.).  AN  EPITOME  OF  PHYSICS  AND  INOR- 
GANIC CHEMISTRY.  12mo.,  216  pages,  illustrated.  Cloth,  $1.00, 
net.     See  Lea's  Series  of  Medical  Epitomes,  page  18. 

AN  EPITOME  OF  ORGANIC  AND  PHYSIOLOGICAL  CHEM- 
ISTRY. 12mo.,  246  pages,  illustrated.  Cloth,  $1,  net.  See  Lea's 
Series  of  Medical  Epitomes,  page  18. 

MAGEE  (M.  D.)  and  JOHNSON  (WALLACE).  AN  EPITOME 
OF  SURGERY.  12mo.,  about  300  pages,  with  130  engravings. 
Cloth,  $1,  net.    Shortly.    See  Lea's  Series  of  Medical  Epitomes,  page  18. 


MAISCH  (JOHN  M.).     A    MANUAL    OF    ORGANIC    MATERIA 
MEDICA.     Seventh  edition,  thoroughly  revised  by  H.  C.  C.  Maisch, 
Ph.  G.,  Ph.  D.    In  one  very  handsome  12mo.  volume  of  512  pages,  with 
285  engravings.     Cloth,  $2.50,  oiet. 
Used  as  text-book  in  every  college  |      The    best  handbook    upon 


macognosy  of  any  published  in  this 
country. — Boston  Med.  &  Sur.  Jour. 


of  pharmacy  in  the  United  States 
and  recommended  in  medical  col- 
leges.— American  Therapist. 

MALSBARY    (GEORGE    E.).      A    POCKET    TEXT-BOOK     OF 
THEORY  AND  PRACTICE  OF  MEDICINE.     In  one  handsome 
12mo.  volume  of  405  pages,  with  45  illustrations.     Cloth,  $1.76,  net ; 
flexible  red  leather,  $2.25,   net.      See  Lea's  Series  of  Pocket   Text- 
books,   page  18. 
Will  readily  commend  itself  to  I  recent  advances  in  medicine  with 
students    and    busy    practitioners,    the   best  of  that  which  is  old.  — 
bringing  forward  as  it  does  the  most '  Medical  Review  of  Revieivs. 

MANTON  (W.  P.).  AN  EPITOME  OF  OBSTETRICS,  12mo,  265 
pages,  82  illustrations.  Cloth,  $1.00,  net.  See  Lea's  Series  of  Medi- 
cal Epitomes,  page  18. 

MARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  In  one  12mo. 
volume  of  468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

MARTIN  (EDWARD).  A  MANUAL  OF  SURGICAL  DIAGNOSIS. 
In  one  12mo.  volume  of  about  400  pp.,  fully  illustrated.      Preparing^ 

MARTIN  (W^ ALTON)  AND  ROCKWELL  (WM.  H.).  A  POCKET 
TEXT-BOOK  OF  CHEMISTRY  AND  PHYSICS.  In  one  hand- 
some 12mo.  volume  of  366  pages,  with  137  illustrations.  Cloth,  $1.50, 
net;  limp  leather,  $2.00,  net.  See  Lea's  Series  of  Pocket  Te.ct- 
hooks,  page  18. 
The  work  accurately  reflects  both  I  ter  is  excellent. — The  Medical  and 

sciences  in    their   present    develop-    Sunjtcul  Monitor. 

merit.    The  arrangement  of  the  mat-  ' 


20     Lea  Beotheks  &  Co.,  Philadelphia  and  New  Yoek. 


3IEDICAIj    EPIT03IE    SERIES. 

Epitonif.^,  page  18. 


See    Lea's    Series    of    Medical 
MEDICAIj  news  pocket  formulary,  see  page  32. 


MITCHELL   (S.   WEIR).      CLINICAL   LESSONS  ON  NERVOUS 
DISEASES.     In  one  12mo.  volume  of  299  pages,  with  19  engravings 
and  2  colored  plates.     Cloth,  $2.50. 
The  book  treats  of  hysteria,  recur- j  contractions,   rotary  movements  in 
rent  melancholia,  disorders  of  sleep,    the  feeble   minded,   etc.     Few   can 
choreic  movements,  false  sensations    speak  with  more  authority  than  the 
ot    cold,   ataxia,   hemiplegic    pain,  I  author. —  The  Journal  of  the  Ameri- 
treatment  of  sciatica,  erythromelal- '  can  Medical  Association. 
gia,  reflex  ocularneurosis,  hysteric  | 

MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF 
INJURIES  OF  NERVES  AND  THEIR  TREATMENT.  In 
one  handsome  12mo.  volume  of  239  pages,  with  12  illustrations. 
Cloth,  $1.75. 

MORROW  (PRINCE  A.).    SOCIAL  DISEASES  AND  MARRIAGE. 

SOCIAL  PROPHYLAXIS.     Octavo,  390   pages.     Cloth  $3.00,   vef. 

Just  reach/. 
This  subject  has  not  previously  i  diseases  which  have  been  introduced 
been  written  upon  in  the  English  into  the  family  life,  and  there  are  no 
language,  and  although  we  are  quite  |  more  dislressingtragedies  than  those 
familiar  with  the  work  of  several  which  follow.  Morrow  discusses 
French  and  German  writers  on  the  I  every  possible  phase  of  the  subject, 
relationship  of  syphilis  and  gon-jand  he  has  made  many  timely  sug- 
orrhojato  marriage,  we  have  nowhere  [  eestions  which  are  both  helpful  and 
seen  a  more  masterly  presentation  of;  hopeful.  This  book  should  be  read 
this  most  important  subject.  There  j  by  every  physician,  and  there  are  a 
is  probably  no  medical  practitioner  lai'ge  number  of  non-medical  readers 
who  does  not  frequently  have  occa-  who  might,  read  it  with  profit. — St. 
sion  to  see  the  ravages  of  venereal  I  Paul  Medical  Journal. 

MUSSER  (JOHN  H.).   A  PRACTICAL  TREATISE  ON  MEDICAL 

DIAGNOSIS,  for  Students  and  Physicians.     New  (5th)  edition,  thor- 
oughly revised.     In  one  octavo  volume  of  1205  pages,  with  395  en- 
gravings and  63  full-page  colored  plates.     Cloth,  $6.50,  wf<;   leather, 
$7.50,  net;  half  Morocco,  $8.00,  net. 
A  few  notices  of  the  previous  edition  are  appended  : 


Musser's  Medical  Diagnosis  has 
become  the  leading  and  standard 
work  on  its  subject.  In  this  work 
every  accepted  method  of  clinical 
and  bedside  investigation  is  de- 
scribed clearly  and  fully,  and  everj^ 
effort  is  made  to  render  the  teachings 
of  the  book  of  such  practical  nature 
as  to  be  readily  available  to  the 
practitioner. — M  e  m  p  h  i  s  Medical 
Monthly. 


This  is  the  best  book  on  medical 
diagnosis  published  in  the  English 
language.  In  it  is  found  everything 
relating  to  the  proper  making  of  a 
correct  diagnosis.  It  is  comijlete, 
l^raetical,  up-to-date, well  illustrated, 
well  arranged,  easy  for  reference, 
and  is  the  best  book  on  medical  diag- 
nosis, both  for  medical  students  and 
for  practitioners. — Maryland  Med- 
ical Journcd. 


NAGELi  (J.  D.).  AN  EPITOME  OF  NERVOUS  AND  MENTAL 
DISEASES.  12mo.,  about  250  pages,  illustrated.  Cloth,  SI,  net. 
See  Lea's  Series  of  Medical  Epito?nes,  page  18. 


Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek.     21 

NATIONAL  DISPENSATORY.  See  SMlVe,  Maisch  d  Caspari,  p.  27. 

NATIONAL!  FORMULARY.  See  Stille,  Maisch  &  Caspari' s  National 
Dispensatory,  page  27. 

NATIONAL.  MEDICAL.  DICTIONARY.     See  Billings,  page  4. 

NETTIiESHIP  (E.).  DISEASES  OF  THE  EYE.  Sixth  edition, 
thoroughly  revised.  In  one  12mo.  volume  of  562  pages,  with  192 
engravings,  and  .5  colored  plates,  test-types,  formulae  and  color- 
blindness test.     Cloth,  $2.25,  net. 

This  work  for  compactness,  practi- 
cality and  clearness  has  no  superior 
in  the  English  language. — Journal 
of  Medicine  and  Science. 


By  far  the  best  student's  text-book 
on  the  subject  of  ophthalmology. — 
The  Clinical  Review. 


NICHOLS  (JOHN  B.)  AND  VALE  (F.  P.).  A  POCKET  TEXT- 
BOOK OF  HISTOLOGY  AND  PATHOLOGY.  In  one  handsome 
12mo.  volume  of  452  pages,  with  213  illustrations.  Cloth,  $1.75,  net : 
flexible  leather,  $2.25,  net.  See  Lea's  Series  of  Pocket  Text-hooks, 
page  18. 

Systematically  arranged,  and  in  I  can  safely  and  conscientiously  rec" 
the  highest  degree  interesting.  '  ommend  it  to  both  students  and 
Thoroughly  up  to  date.  The  book  practitioners. —  The  St.  Louis  Medi- 
is  an  exceptionally  good  one.     We    cal  and  Surgical  Journal. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF 
OPHTHALMOLOGY.  In  one  octavo  volume  of  641  pages,  with  357 
engravings  and  5  colored  plates.     Cloth,  $5 ;  leather,  $6. 

It  is  practical  in   its  teachings,  i  has  ever  been  offered  to  the  Amer- 
We  unreservedly  endorse  it  as  the    ican    medical    -pyxhWc— Annals    oj 
best,  the  safest  and  the  most  compre-    Ophthalmology  and  Otology. 
hensive  volume  upon  the  subject  that 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN. 
In  one  12mo.  volume  of  525  pages,  with  85  engravings  and  4  colored 
plates.     Cloth,  $2.     See  Series  of  Clinical  Manuals,  page  25. 


PARK  (ROSWELL\  EDITOR.  A  TREATISE  ON  SURGERY 
BY  AMERICAN  AUTHORS.  Third  edition.  In  one  royal  octavo 
volume  of  1408  pages,  with  692  engravings  and  64  full-page  plates. 
Cloth,  $7.00,  ne<;  leather,  .$8.00,  7/.e«.  j^^Published  also  in  2  vol- 
umes. Vol.  I,  General  Surgery  and  Surgical  Pathology.  Cloth, 
"^3.75,  net.  Vol.  II,  Special,  Regional  and  Operative  Surgery. 
Cloth,  3.75,  net. 


The  work  is  fresh,  clear  and  practi- 
cal, covering  the  ground  thoroughly 
yet  briefly,  and  well  arranged  for 
rapid  reference,  so  that  it  will  be  of 
special  value  to  the  student  and  busy 
practitioner.  The  pathology  is 
broad,  clear  and  scientific,  while  the 
suggestions     upon     treatment     are 


clear-cut,  thoroughly  modern  and 
admirably  resourceful. — Johns  Hop- 
kins Hospital  Bulletin. 

The  latest  and  best  work  written 
upon  the  science  and  art  of  surgery. 
Columbus  Medical  Journal. 

It  is  thoroughly  practical  and  yet 
thoroughly  scientific. — Med.  Newt. 


22     Lea  Beothkbs  &  Co.,  Philadelphia  and  New  Yoek. 


PARK  (WIL.L.IAM  H.).  BACTERIOLOGY  IN  MEDICINE  AND 
SURGERY.  12mo.,  688  pages,  with  87  illustrations  in  black  and 
colors,  and  2  plates.     Cloth,  $3.00  net. 


This  book  fills  a  very  distinct 
gap.  None  of  the  text-books  in  our 
language  take  up  the  subject  of  bac- 
teriology so  thoroughly  and  so 
soundly  as  does  this  from  the  point 


of  view  of  the  hygienist  and  public 
health  officer.  The  work  is  correct 
and  very  well  up  to  date. — The  Mon- 
treal Medical  Journal, 


PEDERSEN  (V.  C; 

GYNECOLOGY. 


AND  PARKER  (E.  O.).     AN  EPITOME  OF 

See  Lea's  Scries  of  Medical  Ejntomes,  page  18. 


PEPPER  (A.  J.).   SURGICAL  PATHOLOGY.    In  one  12mo.  volume 

of  511  pages,  with  81  engravings.     Cloth,  $2.   See  Student's  Series  of 
Manuals,  p.  27. 

PICK  (T.  PICKERING).      FRACTURES  AND  DISLOCATIONS. 

In  one  12mo.  volume  of  530  pages,  with  93  engravings.      Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

PIjAYPAIR  (W.  S.).  a  TREATISE  ON  THE  SCIENCE  AND 
PRACTICE  OF  MIDWIFERY.  Seventh  American  from  the  ninth 
English  edition.  In  one  octavo  volume  of  700  pages,  with  207 
engravings  and  7  plates.     Cloth,  $3.75  net ;  leather,  $4.75,  net. 


the  ablest  English-speaking  authori- 
ties on  the  obstetric  art. — Buffalo 
3Iedical  and  Surgical  Journal. 


This  work  must  occupy  a  fore- 
most place  in  obstetric  medicine  as 
a  safe  guide  to  both  student  and 
obstetrician.    It  holds  a  place  among 

POCKET  TEXT-BOOKS.   See  page  18. 

POIilTZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE 

KAR    AND    ADJACENT    ORGANS.      New  American    from    the 

f.iurth   German  edition.     In  one  octavo  volume  of  896  pages,   with 

346  original  engravings.     Cloth,  $7.50,  net.     Jusi  ready. 

It  is  an  absolute  sine  qua  non  for    physician  as  a  book    of   reference 

the  practitioner  who  devotes  atten-    upon    these     topics. — American 

tioa   to   otology  or   rhinology,   and    Journal  of  the  Medical  Sciences. 

should   be  in  the  library  of  every 

POSEY  (W.  C.)  AND  W^RIGHT   (JONATHAN),  EDITORS.    A 

TREATISE  ON  THE  EYE,  NOSE,  THROAT  AND  EAR.  By 
Eminent  authorities.  Octavo,  1243  pages,  richly  illustrated  with  650 
engravings  and  35  full-page  plates  in  black  and  colors.  Cloth,  $7.00, 
7iet;  leather,  $8.00,  net ;  half  Morocco,  $8.50,  net. 
Published  also  in  2  volumes.  Volume  I.  Posey  on  the  Eye.  700  pages, 
358  engravings,  19  plates.  Cloth,  $4.00,  net.  Volume  II.  Wright 
on  the  Nose,  Throat  and  Ear.  543  pages,  292  engravings,  16  plates. 
Cloth,  $3.50,  net. 
The  book  is  a  distinct  success.    It 

will  fulfil  the  aims  of  its  editors  and 

win  popularity  among  students  and 

practitioners. — Johns  Hopkins  Hos- 
pital Bulletin. 
This  is  the  best  book  published  in 

the  English  language  upon  the  eye, 

ear,  nose  and  throat.     In  this  work 

every    chapter    is  excellent.      The 

most  recent  theories  and  methods  of 

treatment  are  incorporated.     It  is  a 


book  which  every  specialist  should 
own,  because  he  will  find  in  it  much 
that  cannot  be  found  in  any  other 
work  of  the  kind,  and  the  book  that 
the  general  practitioner  should  pur- 
chase, for  it  is  especially  adapted  to 
his  needs,  is  strictly  up-to-date,  and 
because  he  can  purchase  no  single 
book  which  will  meet  his  wants  as 
thoroughly  as  will  this  work. — 
Northivcstcrn  Lancet. 


Lba  Brothees  &  Co.,  Philadelphia  and  New  Yokk.     23 

POTTS  (CHARLES  S.).  A  POCKET  TEXT-BOOK  OF  NERVOUS 
AND  MENTAL  DISEASES.  In  one  handsome  12mo.  volume  of 
445  pages,  with  8S  engravings.  Cloth,  $1.75,  net;  limp  leather,  $2.25, 
net.    See  Lea's  Series  of  Pocket  Text-books,  page  18. 

student  to  understand  the  essential 


Far  superior  to  the  ordinary  work 
of  its  class.  The  author  has  suc- 
ceeded in  impressing  the  broad  out- 
lines of  the  structure  and  functions 
of  the  nervous  system  so  simply  and 
so  comprehensively,  with  the  aid 
of  a  few  well-selected  diagrams,  as 
to  make  it  compratively  easy  for  the 


plan  of  his  future  study.  The  suc- 
ceeding chapters  on  the  various  dis- 
eases, although  condensed,  are  accu- 
rate and  up-to-date,  and  give  in  a 
few  words  the  most  important  facts. 
— Boston  Medical  and  Surgical  Jonr- 
nal. 


A  TEXTBOOK  ON  MEDICAL  AND  SURGICAL  ELECTRI- 


CITY.    Octavo,  about  350  pages,  amply  illustrated.     Shortly. 
PROGRESSIVE  MEDICINE.     See  page  32. 

PURDY  (CHARLES  W.).  BRIGHT'S  DISEASE  AND  ALLIED 
AFFECTIONS  OF  THE  KIDNEY.  In  one  octavo  volume  of  288 
pages,  with  18  engravings.     Cloth,  $2. 

PYE-SMITH  (PHILIP  H.).  DISEASES  OF  THE  SKIN.  In  one 
12mo.  vol.  of  407  pp.,  with  28  illus.,  18  of  which  are  colored.  Cloth,  $2. 

RALPE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one 
12mo.  volume  of  314  pages,  with  16  engravings.  Cloth,  $1.50.  See 
Student's  Series  of  Mamials,  page  27. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEM- 
ISTRY. Fifth  edition,  thoroughly  revised.  In  one  12mo.  vol- 
ume of  326  pages.     Cloth,  $2. 

REYNOLDS  (EDWARD)  AND  NEWELL  (F.  S.).  A  MANUAL 
OF  PRACTICAL  OBSTETRICS.  Second  and  revised  edition. 
Octavo,  531  pages,  illustrated  with  253  engravinsrs,  and  3  plates. 
Cloth,  $3.75,  7iet.  &  &  >  i 


A  complete  text-book  on  obstetrics, 
characterized  by  a  distinct  accen- 
tuation of  the  practical  side  of  this 
science. — Interstate  Medical  Jourjial. 

Seldom  have  we  found  descriptions 


so  complete,  diagnostic  points  so 
clearly  brought  out,  and  the  line  of 
treatment  of  special  conditions  so 
graphically  drawn. — Tlie  Vircjinia 
Medical  Soni-Monthhj. 


RICHARDSON  (BENJAMIN  WARD).      PREVENTIVE  MEDI- 
CINE.    In  one  octavo  volume  of  729  pages.     Cloth,  $4. 

ROBERTS  (JOHN  B.).     THE  PRINCIPLES  AND  PRACTICE  OF 

MODERN  SURGERY.    Second  and  revised  edition.  Octavo,  838  pages 
with  473  engravings  and  8  plates.  Cloth,  $4  25,  net;  leather,  $5.25,  net. 
A  clear,  concise,   comprehensive  j  satisfactory  or  valuable  single  vol- 


ume work  on  this  subject. — Pacific 
Medical  Journal. 


and  practical  presentation  of  the 
most  modern  surgery.  The  student 
or  practitioner  will  not  find  a  more 

ROBERTS  (SIR  WILIilAM).  A  PRACTICAL  TREATISE  ON 
URINARY  AND  RENAL  DISEASES,  INCLUDING  URINARY 
DEPOSITS.  Fourth  American  from  the  fourth  London  edition.  In 
one  very  handsome  8vo,  vol.  of  609  pp.,  with  81  illus.     Cloth,  $3.50. 


24     Lea  Brothkbs  &  Co.,  Philadelphia  and  New  Yoek. 

ROCKWELLi,  (W.  H.,  Jr.).     A   POCKET   TEXT-BOOK    OF    AN- 
ATOMY.    12mo.,    600    pages,   illustrated.     Cloth,   $2.25,  net;   limp 
leather.  $2.75,  net.       See  Lea's  Series  of  Pocket  Text-books,  page  18. 
An  excellent  example  of  skilful  epitomization.     A  compendious  text- 
book for  the  student  and  a  quick,  handy  work  of  reference  for  the  physician 
or  surgeon.     Exactly  adapted  to  the  needs  of  training  schools  for  nurses. 


ROGER  {G.  H.).  INFECTIOUS  DISEASES.  Translated  by  M.  S. 
Gabriel,  M.D.  Octavo,  864  pages,  41  illustrations.  Cloth,  $6  76  net. 
Just  ready. 


Symptoms,  pathology,  diagnosis, 
prognosis  and  treatment  are  con- 
sidered fully  and  practically.  The 
book  is  the  work  of  a  practical  man 
who  works  from  a  scientific  basis — 
one  who  knows  the  why  and  where- 


fore of  all  things  connected  with  in- 
fectious diseases.  About  two  hun- 
dred pages  are  devoted  to  treatment, 
which  is  presented  in  a  manner  that 
is  at  once  novel  and  yet  eminently 
practical." — l^he  Medical  Standard. 


ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE 
NERVOUS  SYSTEM.  In  one  handsome  octavo  volume  of  726  pages, 
with  184  engravings.     Cloth,  $4.50 ;  leather,  $5.50. 


SCHAFER    (EDWARD   A.).     THE   ESSENTIALS  OF  HISTOL- 
OGY. DESCRIPTIVE  AND  PRACTICAL.     Sixth  edition.    Octavo, 
426  pages,  with  463  illustrations,     Cloth,  $3.00,  net. 
The  most  satisfactory  elementary  ;  lish  language. — The  Boston  Medical 

text-book  of  histology  in  the  Eng-  I  and  Surgical  Journal. 

-A  COURSE   OF  PRACTICAL    HISTOLOGY.    Second  edition. 

In  one  12mo.  volume  of  307  pages,  with  59  engravings.   Cloth,  $2.25. 


SCHALiEK  (A.).  AN  EPITOME  OF  SKIN  DISEASES.  12mo., 
225  pages,  34  engravings.  Cloth,  $1.00,  net.  See  Lea's  Series  of  Med- 
ical Epitomes,  page  18. 


SCHLiEIF  (WILIilAM).  MATERIA  MEDICA,  THERAPEUTICS, 
PRESCRIPTION  WRITING,  MEDICAL  LATIN,  ETC.  Second 
and  revised  edition.  12mo.,  370  pages.  Cloth,  $1.75;  limp  leather, 
$2.25,  net.     See  Lea's  Series  of  Pocket  Text-books,  page  18. 

It  contains  in  a  concise,  definite,  plete  college  courses  on  Materia  Med- 
and  assimilable  form  the  essential  ica  and  Therapeutics. — The  National 
knowledge  required  in  the  most  com-    Medical  Review. 


SCHMAUS  (HANS)  AND  EWING  (JAMES).  PATHOLOGY 
AND  PATHOLOGICAL  ANATOMY.  Sixth  edition.  Octavo,  602 
pages,  with  351  engravings  and  34  plates  in  black  and  colors. 
Cloth,  $4.00,  net. 


This  work  embodies  all  the  re- 
search of  the  best  European  and 
American  observers,  and  is  without 
a  superior,  if  indeed  it  has  an  equal. 
in  this  or  any  other  language.     The 


additions  and  editorial  work  by 
Professor  Ewing  render  the  book 
all  the  more  valuable. — Medical 
Progress. 


SCHMIDT  (LOUIS  E.).  AN  EPITOME  OF  GENITO-URINARY 
AND  VENEREAL  DISEASES.  12mo.,  249  pages,  21  engravings. 
Cloth,  $1,  net.     See  Lea's  Scries  of  Medical  Epitomes,  page  18. 


Lba  Beothkes  &  Co.,  Philadelphia  and  New  York. 


25 


SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edi- 
tion. In  one  octavo  volume  of  268  pages,  with  13  plates,  10  of  which 
are  colored,  and  9  engravings.     Cloth,  $2. 

SERIES  OF  CIiINICAIi  MANUALS.  A  Series  of  Authoritative 
Monographs  on  Important  Clinical  Subjects.  The  following  volumes 
are  now  ready  :  Caiiter  and  Frost's  Ophthalmic  Surgery,  $2.25  ; 
Marsh  on  Diseases  of  the  Joints,  $2;  Owen  on  Surgical  Diseases  of 
Children,  $2;  Pick  on  Fractures  and  Dislocations,  $2. 
For  separate  notices,  see  under  various  authors'  names. 

SERIES  OF  MEDICAIi  EPITOMES.     See  page  18. 
SERIES  OF  POCKET  TEXT-BOOKS.     See  page  18. 


SERIES  OF  STATE  BOARD   EXAMINATION   QUESTIONS. 

See  page  26. 

SIMON  (CHARLES  E.).    A  TEXT-BOOK  ON  PHITSIOLOGICAL 

CHEMISTRY.  Octavo,  453  pages.     Cloth.  $3.25,  net. 


This  book  is  a  deserving  compan- 
ion work  to  Simon's  Clinical  Diag- 
nosis, and  like  it  will  live  to  be- 
come a  standard  and  recognized 
text-book  for  students,  and  a  guide 
for    the    thoughtful    student-physi- 


cian. Simon  has  honored  American 
medicine  in  his  pioneer  work  in  a 
field  which  heretofore  has  been  oc- 
cupied   by    foreign    authors. — The 

Medical  Fortnightly. 


SIMON  (CHARLES  E.).  CLINICAL  DIAGNOSIS,  BY  MICRO- 
SCOPICAL AND  CHEMICAL  METHODS.  New  (oth)  and  revised 
edition.  In  one  octavo  volume  of  695  pages,  with  150  engravings  and 
22  full-page  colored  plates.     Cloth,  $4.00,  net.     Just  ready. 

A  jew  notices  of  the  previous  editions  are  appended. 


This  book  thoroughly  deserves  its 
success.  It  is  a  very  complete,  authen- 
tic and  useful  manual  of  the  micro- 
scopical and  chemical  methods 
which  are  employed  in  diagnosis. 
— A^  Y.  Med.  Journal 


The  chapter  on  examination  of 
the  urine  is  the  most  complete  and 
advanced  that  we  know  of  in  the 
English  language. —  Canadian  Prac- 
titioner. 


SIMON  (TI^M.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures 
and  Laboratory  Work  in  Chemistry.  A  Text-book  specially  adapted 
for  Students  of  Pharmacy  and  Medicine.  Seventh  edition.  In  one 
8vo  volume  of  613  pages,  with  64  engravings  and  8  plates  showing 
colors  of  64  tests,  and  a  spectra  plate.  Cloth,  $3.00,  net. 


It  is  difficult  to  see  how  a  better 
book  could  be  constructed.  No  man 
who  devotes  himself  to  the  practice 
of  medicine  need  know  more  about 
chemistry  than  is  contained  between 
the  covers  of  this  book. — The  North- 
western Lancet. 

Simon's  Chemistry  has  long  been 
a  favorite  with  teachers  and  with 


students.  It  is  clearly  written  and 
beautifully  and  instructively  illus- 
trated. The  frequent  new  editions 
that  are  called  for  allow  the  work  to 
be  kept  up  to  the  latest  researches. 
As  a  text-book  for  medical  students 
it  has  no  superior. — Denver  Medical 
Times. 


SLADE   (D.  D.).     DIPHTHERIA;    ITS    NATURE   AND    TREAT- 
MENT. Second  edition.  In  one  royal  12mo.  vol.,  158  pp.   Cloth,  $1.25. 


26     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.  Eighth  edition,  thoroughly  revised 
and  rewritten  and  much  enlarged.  In  one  large  8vo.  volume  of  983 
pages,  with  273  engravings  and  4  full-page  plates.  Cloth,  $4.50; 
leather,  $5.50. 

For  years  the  leading  text-book  on  \  A  safe  guide  for  students  and  phy- 
children's  diseases  in  America. —  laicieins.—  The  Am.  Jour,  of  Obstetrics. 
Chicago  Medical  Recorder.  \ 

SMITH  (STEPHEN).     OPERATIVE  SURGERY.     Second  and  thor- 
oughly revised  edition.      In  one  octavo  volume  of  892  pages,  with 
1005  engravings.     Cloth,  $4. 
One  of  the  most  satisfactory  works    dium  for  the  modern  surgeon. — Bos- 
on modern  operative    surgery   yet    ton  Medical  and  Surgical  Journal. 
published.     The  book  is  a  compen- 

SOLL.Y  (S.  EDWIN).  A  HANDBOOK  OF  MEDICAL  CLIMi^- 
TOLOGY.  In  one  handsome  octavo  volume  of  462  pages,  with  en- 
gravings and  11  full-page  plates,  5  of  which  are  in  colors.  Cloth,  $4.00. 
A  clear    and   lucid  summary  of  I  to  its  influence  upon  human  beings. 

what  is  known  of  climate  in  relation  I  —The  Therapeutic  Gazette. 

STARK  (31.  ALLEN).  A  TREATISE  ON  ORGANIC  NERVOUS 
DISE  A  SES.  Octavo,  740  pages,  275  engravings  and  26  colored  plates. 
Cloth,  $6.00,  net;  leather,  $7.00,  net;  half  Morocco,  $7.50,  net. 


It  is  gratifying  to  notice  that 
special  care  has  been  exercised 
throughout  the  book  to  give  prom- 
inence to  the  question  of  treatment. 
It  deserves  to  take  its  place  among 
the  best  text-books  in  English  upon 
diseases  of  the  nervous  system. — 
Johns  Hopkins  Hospital  Bulletin. 

Especially  in  regard  to  treatment 
the  statements  are  full  and  precise. 
— Cleveland  Medical  Journal. 


The  best  book  on  organic  nervous 
diseases. — Buffalo  Medical  Journal. 

This  book  is  easily  the  best  that 
has  appeared  in  America.  For  the 
student  it  is  especially  to  be  recom- 
mended and  for  the  neurologist  it 
presents  in  a  brief  and  in  a  very 
attractive  way  the  conclusions  of  a 
very  wide  experience. — Interstate 
Medical  Journal. 


STATE  BOARD  EXAMINATION  SERIES.  CLASSIFIED  AND 
EDITED  BY  R.  J.  E.  SCOTT,  A.M.,  M.D.  Containing,  with 
answers  or  references,  every  question  asked  at  all  of  the  examinations 
held  by  the  New  York  State  Board  of  Medical  Examiners.  The  best 
guides  to  similar  examinations  in  other  States.  In  7  volumes,  bound  in 
flexible  cloth,  each  containing  from  200  to  300  12mo.  pages,  printed 
on  paper  suitable  for  either  pen  or  pencil,  every  other  page,  opposite 
text,  being  left  blank  for  memoranda.  Price,  $1.50  per  volume. 
The  respective  volumes  cover  the  subjects  of  Anatomy,  {ready), 
Chemistry,  (ready),  Obstetrics,  {ready).  Surgery,  {ready).  Practice, 
Materia  Medica  and  Therapeutics,  {ready),  Pathology  and  Diagnosis, 
{ready),  Physiology  and  Hygiene,  {preparing). 

STENHOUSE  (JOHN).     AN  EPITOME    OF    PATHOLOGY.      See 

Lea's  Series  of  Medical  Epitomes,  page  18. 

STLLLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUS- 
ATION, SYMPTOMS,  LESIONS,  PREVENTION  AND  TREAT- 
MENT. In  one  12mo.  volume  of  163  pages,  with  a  chart  showing 
routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS   AND    MATERIA    MEDICA.      Fourth    and 

revised  edition.      In  two  octavo   volumes,  containing    1936    pages. 
Cloth,  $10;  leather,  $12. 


Lea  Bkothees  &  Co.,  Philadelphia  and  New  York.     27 

STTLLiE  (AliFRED),  MAISCH  (JOHN  M.)  AND  CASPARl 
(CHAS.  JR.).  THE  NATIONAL  DISPENSATORY:  Containing 
the  Natural  History,  Chemistry,  Pharmacy,  Actions  and  Uses  of 
Medicines,  including  those  recognized  in  the  latest  Pharmacopceia«  of 
the  United  States,  Great  Britain  and  Germany,  with  numerous  refer- 
ences to  the  French  Codex.  Fifth  edition,  revised  and  enlarged 
including  the  U.  S.  Pharmacopoeia,  Seventh  Decennial  Revision! 
With  Supplement  containing  the  National  Formulary.  In  one 
magnificent  imperial  octavo  volume  of  about  2025  pages  with 
320  engravings.  Cloth,  $7.25;  leather,  $8.  With  ready  reference 
Thumb-letter  Index.     Cloth,  $7.75  ;  leather,  $8.50. 

STIMSON  (LEWIS  A.).    A  MANUAL  OF  OPERATIVE  SURGERY. 

Fourth  edition.     In  one  royal  12mo.  volume  of  581  pages   with  293 
engravings.     Cloth,  $3.00,  net. 


The  book  is  worth  the  price  for  the 
illustrations  alone.— OAto  Medical 
Journal. 

Well  written,  clear,  concise,  prac- 
tical, and  thoroughly  up-to-date  in 


every  particular.  It  covers  the  field 
so  thoroughly  as  to  make  it  a  very 
valuable  text-book  and  a  ready 
reference-book  for  surgeons. — Kan- 
sas City  Medical  Record. 


STIMSON  (LEWIS  A.).      A  TREATISE   ON   FRACTURES    AND 
DISLOCATIONS.      Third   edition.      In  one  handsome   octavo  vol- 
ume of  842  pages,  with  336  engravings  and  32  plates.     Cloth,  $5.00, 
net;  leather,  $6.00, 7ie/!;  half  Morocco,  $6.50,  neZ. 
Preeminently   the    authoritative    value.     The  work  is  profuselv   il- 


text-book  upon  the  subject.  The 
vastexperience  of  the  author  gives 
to  his  conclusions  an  unimpeachable 


lustrated.  It  will  be  found  indis- 
pensable to  the  student  and  the  prac- 
titioner alike.— TAe  Medical  Age. 


STUDENT'S  QUIZ  SERIES.  Thirteen  volumes,  convenient,  author- 
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of  the  Eye,  Ear,  Throat  and  Nose;  11.  Obstetrics;  12.  Gynecology; 
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STUDENT'S  SERIES  OP  MANUALS.  12mos.  of  from  300-540 
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Elements  of  Histology  (5th  edition),  $2.00,  net ;  Pepper's  Surgical 
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Ralfe's  Clinical  Chemistry,  $1.50.  Herman's  First  Lines  in  Mid- 
wifery, $1.25. 

For  separate  notices,  see  under  various  author's  names. 

STURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTER  (W.  NORWOOD).  A  MANUAL  OF  REFRACTION  AND 
MOTILITY.  12mo.,  382  pages,  101  engravings,  4  colored  plates. 
Cloth,  $2,  net.  ^ 

A  text-book  which  can  be  readily  j  The  work  is  devoid  of  bias,  is  direot 
understood    by     the     beginner     in  !  and  accurate,  and  is  undouhtedlv  the 
ophthalmologyand  sufficiently  com- '  best    that    has    been    published   in 
plete  to   meet   the    requirciiients   of  \  KaeatYe&TB.— Medical  Record. 
advanced  students  and  practitioners.  I 


28     Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek. 


SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE 
OVARIES  AND  FALLOPIAN  TUBES.  Including  Abdominal 
Pregnancy.  In  one  12mo.  volume  of  513  pages,  with  119  engravings 
and  5  colored  plates.     Cloth,  $3. 

SZYMONOWICZ    (L.)   AND    MacCALLUM   (J.   BRUCE).       A 

TEXT- BOOK  OF  HISTOLOGY  OF  THE  HUMAN  BODY;  in- 
cluding Microscopical  Technique.  Octavo,  437  pages,  with  277 
original  engravings  and  ,57  inset  plates  in  black  and  colors,  contain- 
ing 81  figures.     Cloth,  .$4.75,  net. 


This  book  will  take  its  place 
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books on  biology. — Journal  Ameri- 
can Medical  Association. 

Eminently  satisfactory   and  well 


adapted  for  teaching  purposes;  the 
text  is  accurate  and  modern,  the 
illustrations  are  extremely  beautiful, 
well  selected  and  numerous. — Medi- 
cal Record. 


TAIT  (liAWSON).     DISEASES  OF  WOMEN  AND  ABDOMINAL 
SURGERY.     Octavo,  546  pages  and  3  plates.    Cloth,  $3. 

TAYLOR   (ALFRED   S.).     MEDICAL    JURISPRUDENCE.     New 

American  from  the  twelfth  English  edition,  specially  revised  by  Clark 

Bell,  Esq.,  of  the  N.  Y.  Bar.     In  one  8vo.  vol.  of  831  pages,  with  54 

engravings  and  8  full-page  plates.     Cloth,  $4.50;  leather,  $5.50. 

To  the  student,  as  to  the  physician,    be  found  to  be  thorough,  authorita- 

we  would  say,  get  Taylor  first,  and    tive     and     modern. — Albany     Law 

then  add  as  means  and  inclination  \  Journal. 

eua\)le  you.— American  Practitioner  \      Probably  the  best  work   on   the 
and  News.  \  subject  written  in  the  English  Ian- 

It  is  the  authority  accepted  as  '  guage.  The  work  has  been  thor- 
final  by  the  courts  of  all  English-  oughly  i-evised  and  is  up  to  date. — 
speaking  countries.    The  work  will  '  Pacific  3Iedical  Journal. 

TAYLOR  (ROBERT  W.).  GENITO-URINARY  AND  VENEREAL 
DISEASES  AND  SYPHILIS.  New  (3d)  and  revised  edition.  In 
one  very  handsome  octavo  volume  of  about  750  pages,  with  153  en- 
gravings and  39  colored  plates.  Cloth,  $5.00,  net;  leather,  $6.00, 
net;  half  morocco,  $6.50,  net.  Just  ready. 
A  few  notices  of  the  previous  edition  are  appended. 
By  long  odds  the  best  work  on  i      It  is  a  veritable  storehouse  of  our 

venereal  diseases. — Louisville  Medi-  ;  knowledge  of  the  venereal  diseases. 

cal  Monthly.  \  It  is  commended  as   a  conservative, 

The  clearest,   most  unbiased  and  I  practical,    full    exposition     of  the 

ably  presented  treatise  as  yet  pub-  ;  gj'eatest    value.  —Chicago    Clinical 

lished    on    this   vast   subject. — The  j  iie^view. 

Medical  News.  ' 

TAYLOR  (ROBERT  TV.).     A  PRACTICAL  TREATISE  ON  SEX- 
UAL   DISORDERS  IN   THE    MALE   AND    FEMALE.      Second 
edition.     In  one  8vo.  volume  of  434  pages,  with  91  engravings  and 
13  colored  plates.     Cloth,  $3.00,  net. 
The  author  has  presented  to  the    followed,  will  be  of  unlimited  value 

profession  the  ablest  and  most  scien-    to    both    physician    and    patient. — 

tific  work  as  yet  published  on  sexual    Medical  News. 

disorders,  and  one  which,  if  carefully 

A  CLINICAL  ATLAS  OF  VENEREAL  AND  SKIN  DISEASES. 

Including  Diagnosis,  Prognosis  and  Treatment.  In  eight  large  folio 
parts,  measuring  14  x  18  inches,  and  comprising  213  beautiful  figures 
on  58  full-page  chromo-lithographic  plates,  85  fine  engravings  and  425 
pages  of  text.  Bound  in  one  volume,  half  Turkey  Morocco,  $28. 
For  tale  by  subscription  only.    Address  the  publishers. 


Lka  Bbotheks  &  Co.,  Philadelphia  and  New  York.    29 

TAYLOR  (SBYMOUR).  INDEX  OF  MEDICINE.  A  Manual  for 
the  use  of  Senior  Students  and  others.  In  one  large  12mo.  volume  of 
802  pages.     Cloth,  $3.75. 

THOMAS  (T.  GAILiLiARD)  AND  MUNDE  (PAUL.  F.).  A  PRAC- 
TICAL TREATISE  ON  THE  DISEASES  OF  WOMEN.  Sixth 
edition.  In  one  octavo  volume  of  824  pages,  with  347  engravings. 
Cloth,  $5 ;  leather,  $6. 

TH03IPS0N  (W.  OILMAN).     A   TEXT-BOOK   OF  PRACTICAL 

MEDICINE.  For  Students  and  Practitioners.  Second  edition,  thor- 
oughly revised.  In  one  handsome  octavo  volume  of  1014  pages, 
with  59  engravings.  Cloth,  $5.00,  net;  leather,  $6.00,  net;  half 
Morocco,  $6.50,  net. 


direct  and  most  satisfying  manner 
he  has  given  in  .sufficient  detail  the 
exact  method  of  treatment  that  has 
commended  itself  to  his  judgment 
and  his  experience. — Medical  Ncios. 


The  author  has  presented  the  rich 
harvest  of  his  ripe  experience  as 
physician  and  teacher.  There  is 
everywhere  ample  evidence  of  accur- 
ate observation,  profound  scholar- 
ship and  rare  good  judgment.     In  a 

THOMPSON  (SIR  HENRY).  THE  PATHOLOGY  AND  TREAT- 
MENT OF  STRICTURE  OF  THE  URETHRA  AND  URINARY 
FISTULA.  From  the  third  English  edition.  In  one  octavo  volume 
of  359  pages,  with  47  engravings  and  3  lithographic  plates.  Cloth, 
$3.50. 

THORNTON  (E.  Q.).  FORMULARY.  See  Medical  News  Pocket 
Fortnularji,  page  32. 

TIRARD  (NESTOR).  MEDICAL  TREATMENT  OF  DISEASES 
AND  SYMPTOMS.     Handsome  octavo  volume  of  627  pages.     Cloth, 

$4.00,  oiet. 
This  work  will  rapidly  come  into  1  this  is  a  work  destined  to  become 
favor  Avith  students  and  practition- 1  popular,  and  we  take  great  pleasure 
ers.  It  deals  comprehensively  with  '  in  commending  it  in  the  highest 
therapeutical  medications  and  pre-  '•  terms. — Nashville  Journal  of  Medi- 
sents  a  great  number  of  well-selected  [  cine  and  Surgery. 
formulas  of  every  day  use.  Certainly  I 

TREVES   (SIR  FREDERICK).     OPERATIVE  SURGERY.     New 

edition,  revised  by  the  author  and  Jonathan  Hutchinson,  .Ik., 
F.R.C.S.  In  two  8vo.  volumes,  containing  1574  pages,  with  474  illus- 
trations. De  luxe  edition,  half  Morocco,  $6.50,  net,  per  volume. 
Just  ready. 

A  SYSTEM  OF  SURGERY.    In   Contributions  by  Twenty-five 

English  Surgeons.  In  two  large  octavo  volumes,  containing  2298 
pages,  with  950  engravings  and  4  plates.     Per  set,  cloth,  $16.00. 

SURGICAL    APPLIED    ANATOMY.      New   edition.      In    one 


12mo.  volume  of  577  pages,  with  80  engravings.     Cloth,  $2.00,  net. 
See  Student's  Series  of  Manuals,  page  27. 

TULEY  (HENRY  E.).    AN  EPITOME  OF  PEDIATRICS.     12mo., 

266  pages,  33  engravings.    Cloth,  $1,  net.     See  Lea's  Series  of  Medical 
Epitomes,  page  18. 

TUTTLE  (GEORGE  M.).   A  POCKET  TEXT-BOOK  OF  DISEASES 

OF  CHILDREN.    In    one  handsome  12mo.   volume  of  ,374  pages, 

with  5  plates.   Cloth,  $1.50,  net ;  flexible  red  leather,  $2.00,  net.      See 

Lea's  Series  of  Pocket  Text-hooks,  page  18. 

It  is  a  good  work — the  author  hav-  i  of  infancy  and  childhood  into  short 

ing  condensed  most  of  the  leading    and    readable    chapters. —  Virginia 

points  in  connection  with  diseases  I  Medical  Semi-Monthly. 


30     Lka  Brothkbs  &  Co.,  Philadelphia  and  Nkw  York. 


VAUGHAN    (VICTOR    C.)    AND    NOVY    (FREDERICK    G.). 

CELLULAR  TOXINS,  or  the  Chemical  Factors  in  the  Causation  of 
Disease.  New  (4th)  edition.  In  one  12mo.  volume  of  480  pages.  Cloth, 
$3.00,  net. 

The  work  has  been  brought  down  1  The  most  exhaustive  and  most  re" 
to  date,  and  will  be  found  entirely  '  cent  presentation  of  the  subject. — 
satisfactory. — Journal  of  theAmeri-  j  American  Jour,  of  the  Med.  Sciences, 
can  Medical  Association. 


VEASEY  (CLARENCE  A.).  A  MANUAL  OF  OPHTHALMOLOGY. 
12mo.,  410  pages,  194  engravings,  10  colored  plates.     Cloth,  $2.00,  net. 


The  best  eye  manual  we  have 
seen.  A  handy  volume,  clearly, 
concisely,  conservatively  written 
and  well  arranged.  The  treatment 
is  well  up-to-date — Journal  of 
Ophthalmology,  Otology  and  Laryn- 
gology. 

A  very  attractive,  practical  and 


interesting  volume.  A  book  that 
should  be  constantly  in  the  hands 
of  the  studentof  ophthalmology,  and 
one  well  suited  for  the  busy  oculist 
who,  in  the  midst  of  his  work,  may 
not  have  time  to  look  up  more  ex-, 
tensive  volumes.  St.  Paul  Medical 
Journal. 


VISITING     IjIST.       the    MEDICAL    NEWS    VISITING    LIST. 

Four  styles:  Weekly  (dated  for  30  patients);  Monthly  (undated  for 
120  patients  per  month) ;  Perpetual  (undated  for  30  patients  each 
week);  and  Perpetual  (undated  for  60  patients  each  week).  The  60- 
patient  book  consists  of  256  pages  of  assorted  blanks.  The  first  three 
styles  contain  32  pages  of  important  data,  thoroughly  revised,  and 
160  pages  of  assorted  blanks.  Each  in  one  volume,  price,  $1.25. 
With  thumb-letter  index  for  quick  use,  25  cents  extra.  Special  rates 
to  subscribers  to  The  Medical  Nevts  or  The  American 
Journal  op  the  Medical  Sciences,  or  both.  See  p.  32. 


von  BERGMANN  (E.),  von  BRUNS  (P.)  and  von  MIKULICZ  (J.) 

A  SYSTEM  OF  PRACTICAL  SURGERY.  Translated  and  edited 
under  the  supervision  of  William  T.  Bull,  M.D.  In  five  imperial 
octavo  volumes  containing  over  4000  pages,  with  about  1600  engrav- 
ings and  110  full-page  colored  plates.  Per  volume,  cloth,  $6,  ?ie^ ; 
leather,  $7,  net ;  library  binding,  $7,  net ;  half  Morocco,  $8.50,  net.  For 
sale  by  subscription  only.     Full  prospectus  on  application. 


The  work  is  an  exhaustive  one, 
and  in  its  entirety  will  form  a  com- 
plete encyclopedia  of  modern  surgi- 
cal knowledge.  Abundant  data,  the 
result  of  careful,  original  research  in 
special  fields,  are  published,  with  ex- 
act clinical  reports  that  are  of  im- 
mense practical  value.     As  a  whole. 


the  series  forms  the  most  important 
surgical  work  of  the  day,  and  it  will 
be  found  of  incalculable  value  to  the 
student  and  to  the  scientific  surgeon, 
as  reflecting  the  most  advanced  and 
approved  methods  of  modern  surgi- 
cal practice. — Detroit  Medical 
Journal. 


WATHEN  (JOHN  R.).     AN  EPITOME  OF  HISTOLOGY.     12mo., 

229  Images  with  114  engravings;     Cloth,  $1,  ne<.      See  Lea's  Series  of 
Medical  Epitomes,  page  IS. 


WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  American  from  the  fifth  and 
enlarged  English  edition,  with  additions  by  H.  Hartshorne,  M.  D. 
In  two  large  8vo.  vols,  of  1840  pp.,  with  190  cuts.  Cloth,  $9 ;  leather,  $11. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


31 


WHARTON  (HENRY  R.).  MINOR  SURGERY  AND  BANDAG- 
ING. Fifth  edition.  In  one  12rao.  volume  of  640  pages,  with 
509  engravings,  many  of  which  are  photographic.     Cloth,  $3.00,  net. 


The  part  devoted  to  bandaging  is 
perhaps  the  best  exposition  of  the 
subject  in  the  English  language.  It 
3an  be  highly  commended  to  the 
student,  the  practitioner  and  the 
specialist.— 7%e  Chicago  Medical 
Recorder. 


Well  written,  conveniently  ar- 
ranged and  amplv  illustrated.  It 
covers  the  field  so  fully  as  to  render 
it  a  valuable  text-book,  as  well  as  a 
work  of  ready  reference  for  sur- 
geons.—iVor^A    Amer.  Practitioner. 


WHITLA   (WILLIAM).       DICTIONARY    OF    TREATMENT    OR 

THERAPEUTIC  INDEX.     Including  Medical  and  Surgical  Thera- 
peutics.    In  one  square  octavo  volume  of  917  pages.     Cloth,  $4. 

WHITMAN  (ROYAL).  ORTHOPEDIC  SURGERY.  New  (2d) 
edition,  thoroughly  revised.  Octavo,  843  pages,  with  507  engravino^s 
mostly  original.     Cloth,  $5.50,  net.  * 


branch.  The  text  is  clear  and  the 
views  expressed  are  well  presented, 
making  the  work  the  best  that  has 
yet  been  offered  in  this  important 
branch.— T/ie   Boston  Medical  and 


The  standard  authority  on  ortho- 
pedic surgery.  —  Virginia  Medical 
Mo7ithly. 

It  is  a  pleasure  to  review  a  book 
so  well  written  and  so  clearly  illus- 
trated  as   this,   presenting   the  last  j  Surgical  Journal. 
and  best  word  on  this  active  special  i 

WICKS  (MAUD  A.).  A  POCKET  TEXT-BOOK  OF  NURSING 
Preparing.     See   Lea's   Series   of  Pocket   Text-books,  page  18. 

WILLIAMS  (DAWSON).     THE  MEDICAL  DISEASES  OF  CHIL- 
DREN.     Second  edition.      Specially  revised  for  America  by  F.  S. 
Churchill,  A.M.,  M.D.     In  one  octavo  volume  of  538  pages    with 
52  illustrations,  and  2  plates.     Cloth,  $3.50,  7iet. 
The  descriptions  of  symptoms  are  I  diagnosis,  prognosis,  complications 

tull,  and  the  treatment  recommended  I  and  treatment.    The  work  is  up  to 

will  meet  general  approval.    Under  [  date  in  every  sense.— The  Charlotte 

each  disease  are  given  the  symptoms,  I  Medical  Journal. 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY 
A  new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings.  In  one  octavo  volume  of  616  pages.  Cloth  $4  • 
leather,  $5.  t-  o  ,  -v   , 

WOOLSEY  (GEORGE).     APPLIED  SURGICAL  ANATOMY  RE- 
GIONALLY PRESENTED.     Octavo,  511  pages,  with  125  original 
-     Cloth,  .$5.00,  net ;  leather,  $6.00, 7ief. 


illustrations  in  black  and  colors 
A  happy  union  of  fact  and  prac- 
tice, the  latter  based  upon  the  for- 
mer, which  brings  into  distinct  view 
thp  enhanced  advantage  that  can  be 
taken  of  this  combination.  The 
book  bristles  with  good  advice.  It 
is  a  book  of  remarkable  merit,  show- 


„  not  merely  a  large  amount  of 
research,  but  also  the  faculty  of 
giving  to  each  anatomical  fact  its 
vahie  when  applied  in  practice. 
The  work  is  sufficiently  illustrated. 
—American  Journal  of  the  Medical 
Sciences. 


ZAPFFE  (F.  C).  A  POCKET  TEXT-BOOK  OF  BACTERIOLOGY. 
Handsome  12mo.  of  360  pages,  amply  illustrated  with  146  engravings 
and  7  colored  plates.  Cloth,  ^\.hQ,net;  limp  leather,  $2.00,  7/r< 
See  Lcn  .s-  Sfrie^  of  Pocket  Texl-hooks,  page  18.  ' 


A  most  thorough  and  jinuttical 
book,  written  for  the  needs  of  both 
students  and  practitioners. — Louis- 


ville Journal  of  Medicine  and  Sur- 
gery. 


PERIODICALS. 


PROGRESSIVE  MEDICINE. 

A  Quarterly  Digest  of  New  Methods,  Discoveries,  and  Improvements 
in  the  Medical  and  Surgical  Sciences  by  Eminent  Authorities.  Edited  by 
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Montlily,  Sglo.OO  Per  Annum. 

Each  issue  contains  192  octavo  pages,  fully  illustrated.     The  most 
advanced  and  enterprising  American  exponent  of  scientific  medicine. 


THE  MEDICAL  NEWS  VISITING  LIST. 

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COLUMBIA  UNIVERSITY  LIBRARIES  (hsistx) 

RC  341  P85  1900  C.I 

Nervous  and  mental  diseases 


2002257432 


Neurology 
1905 

Answer  any  two  of  the  following  four  questions. 

1.  What  is  the  essential  lesion  in  lead  paralysis.? 
Describe  the  usual  distribution  of  the  paralysis,  the 
symptoms,  and  what  you  would  expect  to  find  on  physi- 
cal examination. 

2.  Draw  a  diagram  of  the  distribution  of  sensation 
supplied  by  the  spinal  roots  in  the  arm  and  hand. 

3.  Give  the  chief  and  essential  symptoms  (positive 
and  negative)  in  Tabes  Dorsalis,  stating  which  are  the 
symptoms  and  physical  signs  of  the  early  stage  and  which 
of  the  later  stages.  Describe  briefly  the  course  and  dura- 
tion of  the  disease. 

4.  Give  the  positive  and  negative  symptoms  in  a 
complete  transverse  lesion  of  the  spinal  cord  in  the  cervi- 
cal enlargement, distinguishing  between  (a)  those  in  parts 
of  the  body  supplied  by  the  diseased  segment,  and  (b) 
those  by  segments  below. 


Neuro-Pathology 

Draw  a  cross-seclion  of  the  thoracic  portion  of  the 
spinal  cord  and  thoroughly  explain  it.  By  this  is  meant 
(a)  name  the  different  parts ;  (b)  state  where  the  differ- 
ent fibres  of  the  white  matter  come  from,  trace  (roughly) 
their  course,  and  give  their  destination.  In  the  same 
way  tell  where  the  axis  cylinders  of  the  cell  masses  go 
to.  (c)  State  to  what  mechanisms  the  different  sets  of 
fibres  and  cells  belong,  and,  as  far  as  possible,  what  is 
their  function,  (d)  State  to  what  symptoms  a  lesion 
of  those  parts  gives  rise  which  belong  to  a  sensory  and 
motor  mechanism. 


